|
SHEET SPLIT WITH ADHESIVE 89301
|
Facility
|
OP
|
$164.00
|
|
| Hospital Charge Code |
2963274
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$45.92 |
| Max. Negotiated Rate |
$656.00 |
| Rate for Payer: Aetna Commercial |
$147.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$141.04
|
| Rate for Payer: Aetna Managed Medicare |
$45.92
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$106.60
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$82.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$78.72
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$86.92
|
| Rate for Payer: Cash Price |
$49.20
|
| Rate for Payer: Cigna Commercial |
$150.88
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$91.77
|
| Rate for Payer: Health EOS Commercial |
$145.96
|
| Rate for Payer: HFN Commercial |
$150.88
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$123.00
|
| Rate for Payer: Multiplan Commercial |
$131.20
|
| Rate for Payer: NAPHCARE Commercial |
$98.40
|
| Rate for Payer: Preferred Network Access Commercial |
$150.88
|
| Rate for Payer: Quartz Beloit One Network |
$80.36
|
| Rate for Payer: Quartz Commercial |
$106.60
|
| Rate for Payer: Quartz Medicare Advantage |
$98.40
|
| Rate for Payer: The Alliance Commercial |
$656.00
|
| Rate for Payer: WEA Trust Commercial |
$90.20
|
| Rate for Payer: WPS Commercial |
$121.47
|
|
|
SHEET SPLIT WITH ADHESIVE 89301
|
Facility
|
IP
|
$164.00
|
|
| Hospital Charge Code |
2963274
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$80.36 |
| Max. Negotiated Rate |
$150.88 |
| Rate for Payer: Aetna Commercial |
$147.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$141.04
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$86.92
|
| Rate for Payer: Cash Price |
$49.20
|
| Rate for Payer: Cigna Commercial |
$150.88
|
| Rate for Payer: Health EOS Commercial |
$145.96
|
| Rate for Payer: HFN Commercial |
$150.88
|
| Rate for Payer: Multiplan Commercial |
$131.20
|
| Rate for Payer: NAPHCARE Commercial |
$98.40
|
| Rate for Payer: Preferred Network Access Commercial |
$150.88
|
| Rate for Payer: Quartz Beloit One Network |
$80.36
|
| Rate for Payer: Quartz Commercial |
$98.40
|
| Rate for Payer: WEA Trust Commercial |
$90.20
|
| Rate for Payer: WPS Commercial |
$121.47
|
|
|
SHEET TRANSVERSE LAP 72 x 119 89281
|
Facility
|
IP
|
$194.00
|
|
| Hospital Charge Code |
2963259
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$95.06 |
| Max. Negotiated Rate |
$178.48 |
| Rate for Payer: Aetna Commercial |
$174.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$166.84
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$102.82
|
| Rate for Payer: Cash Price |
$58.20
|
| Rate for Payer: Cigna Commercial |
$178.48
|
| Rate for Payer: Health EOS Commercial |
$172.66
|
| Rate for Payer: HFN Commercial |
$178.48
|
| Rate for Payer: Multiplan Commercial |
$155.20
|
| Rate for Payer: NAPHCARE Commercial |
$116.40
|
| Rate for Payer: Preferred Network Access Commercial |
$178.48
|
| Rate for Payer: Quartz Beloit One Network |
$95.06
|
| Rate for Payer: Quartz Commercial |
$116.40
|
| Rate for Payer: WEA Trust Commercial |
$106.70
|
| Rate for Payer: WPS Commercial |
$143.70
|
|
|
SHEET TRANSVERSE LAP 72 x 119 89281
|
Facility
|
OP
|
$194.00
|
|
| Hospital Charge Code |
2963259
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$54.32 |
| Max. Negotiated Rate |
$776.00 |
| Rate for Payer: Aetna Commercial |
$174.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$166.84
|
| Rate for Payer: Aetna Managed Medicare |
$54.32
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$126.10
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$97.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$93.12
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$102.82
|
| Rate for Payer: Cash Price |
$58.20
|
| Rate for Payer: Cigna Commercial |
$178.48
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$108.56
|
| Rate for Payer: Health EOS Commercial |
$172.66
|
| Rate for Payer: HFN Commercial |
$178.48
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$145.50
|
| Rate for Payer: Multiplan Commercial |
$155.20
|
| Rate for Payer: NAPHCARE Commercial |
$116.40
|
| Rate for Payer: Preferred Network Access Commercial |
$178.48
|
| Rate for Payer: Quartz Beloit One Network |
$95.06
|
| Rate for Payer: Quartz Commercial |
$126.10
|
| Rate for Payer: Quartz Medicare Advantage |
$116.40
|
| Rate for Payer: The Alliance Commercial |
$776.00
|
| Rate for Payer: WEA Trust Commercial |
$106.70
|
| Rate for Payer: WPS Commercial |
$143.70
|
|
|
SHEILD SPLASH STERILE ZEROWET #SS-100
|
Facility
|
OP
|
$62.00
|
|
| Hospital Charge Code |
2969559
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$17.36 |
| Max. Negotiated Rate |
$248.00 |
| Rate for Payer: Aetna Commercial |
$55.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$53.32
|
| Rate for Payer: Aetna Managed Medicare |
$17.36
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$40.30
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$31.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$29.76
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$32.86
|
| Rate for Payer: Cash Price |
$18.60
|
| Rate for Payer: Cigna Commercial |
$57.04
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$34.70
|
| Rate for Payer: Health EOS Commercial |
$55.18
|
| Rate for Payer: HFN Commercial |
$57.04
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$46.50
|
| Rate for Payer: Multiplan Commercial |
$49.60
|
| Rate for Payer: NAPHCARE Commercial |
$37.20
|
| Rate for Payer: Preferred Network Access Commercial |
$57.04
|
| Rate for Payer: Quartz Beloit One Network |
$30.38
|
| Rate for Payer: Quartz Commercial |
$40.30
|
| Rate for Payer: Quartz Medicare Advantage |
$37.20
|
| Rate for Payer: The Alliance Commercial |
$248.00
|
| Rate for Payer: WEA Trust Commercial |
$34.10
|
| Rate for Payer: WPS Commercial |
$45.92
|
|
|
SHEILD SPLASH STERILE ZEROWET #SS-100
|
Facility
|
IP
|
$62.00
|
|
| Hospital Charge Code |
2969559
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$30.38 |
| Max. Negotiated Rate |
$57.04 |
| Rate for Payer: Aetna Commercial |
$55.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$53.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$32.86
|
| Rate for Payer: Cash Price |
$18.60
|
| Rate for Payer: Cigna Commercial |
$57.04
|
| Rate for Payer: Health EOS Commercial |
$55.18
|
| Rate for Payer: HFN Commercial |
$57.04
|
| Rate for Payer: Multiplan Commercial |
$49.60
|
| Rate for Payer: NAPHCARE Commercial |
$37.20
|
| Rate for Payer: Preferred Network Access Commercial |
$57.04
|
| Rate for Payer: Quartz Beloit One Network |
$30.38
|
| Rate for Payer: Quartz Commercial |
$37.20
|
| Rate for Payer: WEA Trust Commercial |
$34.10
|
| Rate for Payer: WPS Commercial |
$45.92
|
|
|
SHELL 44MM TRABEC CLUSTER 6202-44-22
|
Facility
|
IP
|
$1,212.00
|
|
| Hospital Charge Code |
2967815
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$593.88 |
| Max. Negotiated Rate |
$1,115.04 |
| Rate for Payer: Aetna Commercial |
$1,090.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,042.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$642.36
|
| Rate for Payer: Cash Price |
$363.60
|
| Rate for Payer: Cigna Commercial |
$1,115.04
|
| Rate for Payer: Health EOS Commercial |
$1,078.68
|
| Rate for Payer: HFN Commercial |
$1,115.04
|
| Rate for Payer: Multiplan Commercial |
$969.60
|
| Rate for Payer: NAPHCARE Commercial |
$727.20
|
| Rate for Payer: Preferred Network Access Commercial |
$1,115.04
|
| Rate for Payer: Quartz Beloit One Network |
$593.88
|
| Rate for Payer: Quartz Commercial |
$727.20
|
| Rate for Payer: WEA Trust Commercial |
$666.60
|
| Rate for Payer: WPS Commercial |
$897.73
|
|
|
SHELL 44MM TRABEC CLUSTER 6202-44-22
|
Facility
|
OP
|
$1,212.00
|
|
| Hospital Charge Code |
2967815
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$339.36 |
| Max. Negotiated Rate |
$4,848.00 |
| Rate for Payer: Aetna Commercial |
$1,090.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,042.32
|
| Rate for Payer: Aetna Managed Medicare |
$339.36
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$787.80
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$606.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$581.76
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$642.36
|
| Rate for Payer: Cash Price |
$363.60
|
| Rate for Payer: Cigna Commercial |
$1,115.04
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$678.24
|
| Rate for Payer: Health EOS Commercial |
$1,078.68
|
| Rate for Payer: HFN Commercial |
$1,115.04
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$909.00
|
| Rate for Payer: Multiplan Commercial |
$969.60
|
| Rate for Payer: NAPHCARE Commercial |
$727.20
|
| Rate for Payer: Preferred Network Access Commercial |
$1,115.04
|
| Rate for Payer: Quartz Beloit One Network |
$593.88
|
| Rate for Payer: Quartz Commercial |
$787.80
|
| Rate for Payer: Quartz Medicare Advantage |
$727.20
|
| Rate for Payer: The Alliance Commercial |
$4,848.00
|
| Rate for Payer: WEA Trust Commercial |
$666.60
|
| Rate for Payer: WPS Commercial |
$897.73
|
|
|
SHELL 62MM CONTINUUM 00-8757-062-01
|
Facility
|
IP
|
$11,318.00
|
|
| Hospital Charge Code |
2967836
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,545.82 |
| Max. Negotiated Rate |
$10,412.56 |
| Rate for Payer: Aetna Commercial |
$10,186.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$9,733.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,998.54
|
| Rate for Payer: Cash Price |
$3,395.40
|
| Rate for Payer: Cigna Commercial |
$10,412.56
|
| Rate for Payer: Health EOS Commercial |
$10,073.02
|
| Rate for Payer: HFN Commercial |
$10,412.56
|
| Rate for Payer: Multiplan Commercial |
$9,054.40
|
| Rate for Payer: NAPHCARE Commercial |
$6,790.80
|
| Rate for Payer: Preferred Network Access Commercial |
$10,412.56
|
| Rate for Payer: Quartz Beloit One Network |
$5,545.82
|
| Rate for Payer: Quartz Commercial |
$6,790.80
|
| Rate for Payer: WEA Trust Commercial |
$6,224.90
|
| Rate for Payer: WPS Commercial |
$8,383.24
|
|
|
SHELL 62MM CONTINUUM 00-8757-062-01
|
Facility
|
OP
|
$11,318.00
|
|
| Hospital Charge Code |
2967836
|
|
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 64MM CONTINUUM SZ OO 00-8757-064-01
|
Facility
|
OP
|
$10,900.00
|
|
| Hospital Charge Code |
2967837
|
|
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 64MM CONTINUUM SZ OO 00-8757-064-01
|
Facility
|
IP
|
$10,900.00
|
|
| Hospital Charge Code |
2967837
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,341.00 |
| Max. Negotiated Rate |
$10,028.00 |
| Rate for Payer: Aetna Commercial |
$9,810.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$9,374.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,777.00
|
| Rate for Payer: Cash Price |
$3,270.00
|
| Rate for Payer: Cigna Commercial |
$10,028.00
|
| Rate for Payer: Health EOS Commercial |
$9,701.00
|
| Rate for Payer: HFN Commercial |
$10,028.00
|
| Rate for Payer: Multiplan Commercial |
$8,720.00
|
| Rate for Payer: NAPHCARE Commercial |
$6,540.00
|
| Rate for Payer: Preferred Network Access Commercial |
$10,028.00
|
| Rate for Payer: Quartz Beloit One Network |
$5,341.00
|
| Rate for Payer: Quartz Commercial |
$6,540.00
|
| Rate for Payer: WEA Trust Commercial |
$5,995.00
|
| Rate for Payer: WPS Commercial |
$8,073.63
|
|
|
SHELL 66MM CONTINUUM 00-8757-066-01
|
Facility
|
IP
|
$10,900.00
|
|
| Hospital Charge Code |
2967838
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,341.00 |
| Max. Negotiated Rate |
$10,028.00 |
| Rate for Payer: Aetna Commercial |
$9,810.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$9,374.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,777.00
|
| Rate for Payer: Cash Price |
$3,270.00
|
| Rate for Payer: Cigna Commercial |
$10,028.00
|
| Rate for Payer: Health EOS Commercial |
$9,701.00
|
| Rate for Payer: HFN Commercial |
$10,028.00
|
| Rate for Payer: Multiplan Commercial |
$8,720.00
|
| Rate for Payer: NAPHCARE Commercial |
$6,540.00
|
| Rate for Payer: Preferred Network Access Commercial |
$10,028.00
|
| Rate for Payer: Quartz Beloit One Network |
$5,341.00
|
| Rate for Payer: Quartz Commercial |
$6,540.00
|
| Rate for Payer: WEA Trust Commercial |
$5,995.00
|
| Rate for Payer: WPS Commercial |
$8,073.63
|
|
|
SHELL 66MM CONTINUUM 00-8757-066-01
|
Facility
|
OP
|
$10,900.00
|
|
| Hospital Charge Code |
2967838
|
|
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 68MM CONTINUUM 00-8757-068-01
|
Facility
|
IP
|
$10,900.00
|
|
| Hospital Charge Code |
2967839
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,341.00 |
| Max. Negotiated Rate |
$10,028.00 |
| Rate for Payer: Aetna Commercial |
$9,810.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$9,374.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,777.00
|
| Rate for Payer: Cash Price |
$3,270.00
|
| Rate for Payer: Cigna Commercial |
$10,028.00
|
| Rate for Payer: Health EOS Commercial |
$9,701.00
|
| Rate for Payer: HFN Commercial |
$10,028.00
|
| Rate for Payer: Multiplan Commercial |
$8,720.00
|
| Rate for Payer: NAPHCARE Commercial |
$6,540.00
|
| Rate for Payer: Preferred Network Access Commercial |
$10,028.00
|
| Rate for Payer: Quartz Beloit One Network |
$5,341.00
|
| Rate for Payer: Quartz Commercial |
$6,540.00
|
| Rate for Payer: WEA Trust Commercial |
$5,995.00
|
| Rate for Payer: WPS Commercial |
$8,073.63
|
|
|
SHELL 68MM CONTINUUM 00-8757-068-01
|
Facility
|
OP
|
$10,900.00
|
|
| Hospital Charge Code |
2967839
|
|
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 BIPOLAR 40 MM 5001-40
|
Facility
|
OP
|
$4,860.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2967811
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,360.80 |
| Max. Negotiated Rate |
$19,440.00 |
| Rate for Payer: Aetna Commercial |
$4,374.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,179.60
|
| Rate for Payer: Aetna Managed Medicare |
$1,360.80
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,159.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,430.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,332.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,575.80
|
| Rate for Payer: Cash Price |
$1,458.00
|
| Rate for Payer: Cigna Commercial |
$4,471.20
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,719.66
|
| Rate for Payer: Health EOS Commercial |
$4,325.40
|
| Rate for Payer: HFN Commercial |
$4,471.20
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,645.00
|
| Rate for Payer: Multiplan Commercial |
$3,888.00
|
| Rate for Payer: NAPHCARE Commercial |
$2,916.00
|
| Rate for Payer: Preferred Network Access Commercial |
$4,471.20
|
| Rate for Payer: Quartz Beloit One Network |
$2,381.40
|
| Rate for Payer: Quartz Commercial |
$3,159.00
|
| Rate for Payer: Quartz Medicare Advantage |
$2,916.00
|
| Rate for Payer: The Alliance Commercial |
$19,440.00
|
| Rate for Payer: WEA Trust Commercial |
$2,673.00
|
| Rate for Payer: WPS Commercial |
$3,599.80
|
|
|
SHELL BIPOLAR 40 MM 5001-40
|
Facility
|
IP
|
$4,860.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2967811
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,381.40 |
| Max. Negotiated Rate |
$4,471.20 |
| Rate for Payer: Aetna Commercial |
$4,374.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,179.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,575.80
|
| Rate for Payer: Cash Price |
$1,458.00
|
| Rate for Payer: Cigna Commercial |
$4,471.20
|
| Rate for Payer: Health EOS Commercial |
$4,325.40
|
| Rate for Payer: HFN Commercial |
$4,471.20
|
| Rate for Payer: Multiplan Commercial |
$3,888.00
|
| Rate for Payer: NAPHCARE Commercial |
$2,916.00
|
| Rate for Payer: Preferred Network Access Commercial |
$4,471.20
|
| Rate for Payer: Quartz Beloit One Network |
$2,381.40
|
| Rate for Payer: Quartz Commercial |
$2,916.00
|
| Rate for Payer: WEA Trust Commercial |
$2,673.00
|
| Rate for Payer: WPS Commercial |
$3,599.80
|
|
|
SHELL BIPOLAR 41 MM 5001-41
|
Facility
|
IP
|
$4,860.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2967812
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,381.40 |
| Max. Negotiated Rate |
$4,471.20 |
| Rate for Payer: Aetna Commercial |
$4,374.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,179.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,575.80
|
| Rate for Payer: Cash Price |
$1,458.00
|
| Rate for Payer: Cigna Commercial |
$4,471.20
|
| Rate for Payer: Health EOS Commercial |
$4,325.40
|
| Rate for Payer: HFN Commercial |
$4,471.20
|
| Rate for Payer: Multiplan Commercial |
$3,888.00
|
| Rate for Payer: NAPHCARE Commercial |
$2,916.00
|
| Rate for Payer: Preferred Network Access Commercial |
$4,471.20
|
| Rate for Payer: Quartz Beloit One Network |
$2,381.40
|
| Rate for Payer: Quartz Commercial |
$2,916.00
|
| Rate for Payer: WEA Trust Commercial |
$2,673.00
|
| Rate for Payer: WPS Commercial |
$3,599.80
|
|
|
SHELL BIPOLAR 41 MM 5001-41
|
Facility
|
OP
|
$4,860.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2967812
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,360.80 |
| Max. Negotiated Rate |
$19,440.00 |
| Rate for Payer: Aetna Commercial |
$4,374.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,179.60
|
| Rate for Payer: Aetna Managed Medicare |
$1,360.80
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,159.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,430.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,332.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,575.80
|
| Rate for Payer: Cash Price |
$1,458.00
|
| Rate for Payer: Cigna Commercial |
$4,471.20
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,719.66
|
| Rate for Payer: Health EOS Commercial |
$4,325.40
|
| Rate for Payer: HFN Commercial |
$4,471.20
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,645.00
|
| Rate for Payer: Multiplan Commercial |
$3,888.00
|
| Rate for Payer: NAPHCARE Commercial |
$2,916.00
|
| Rate for Payer: Preferred Network Access Commercial |
$4,471.20
|
| Rate for Payer: Quartz Beloit One Network |
$2,381.40
|
| Rate for Payer: Quartz Commercial |
$3,159.00
|
| Rate for Payer: Quartz Medicare Advantage |
$2,916.00
|
| Rate for Payer: The Alliance Commercial |
$19,440.00
|
| Rate for Payer: WEA Trust Commercial |
$2,673.00
|
| Rate for Payer: WPS Commercial |
$3,599.80
|
|
|
SHELL BIPOLAR 42 MM 5001-42
|
Facility
|
OP
|
$4,860.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2969403
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,360.80 |
| Max. Negotiated Rate |
$19,440.00 |
| Rate for Payer: Aetna Commercial |
$4,374.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,179.60
|
| Rate for Payer: Aetna Managed Medicare |
$1,360.80
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,159.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,430.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,332.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,575.80
|
| Rate for Payer: Cash Price |
$1,458.00
|
| Rate for Payer: Cigna Commercial |
$4,471.20
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,719.66
|
| Rate for Payer: Health EOS Commercial |
$4,325.40
|
| Rate for Payer: HFN Commercial |
$4,471.20
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,645.00
|
| Rate for Payer: Multiplan Commercial |
$3,888.00
|
| Rate for Payer: NAPHCARE Commercial |
$2,916.00
|
| Rate for Payer: Preferred Network Access Commercial |
$4,471.20
|
| Rate for Payer: Quartz Beloit One Network |
$2,381.40
|
| Rate for Payer: Quartz Commercial |
$3,159.00
|
| Rate for Payer: Quartz Medicare Advantage |
$2,916.00
|
| Rate for Payer: The Alliance Commercial |
$19,440.00
|
| Rate for Payer: WEA Trust Commercial |
$2,673.00
|
| Rate for Payer: WPS Commercial |
$3,599.80
|
|
|
SHELL BIPOLAR 42 MM 5001-42
|
Facility
|
IP
|
$4,860.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2969403
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,381.40 |
| Max. Negotiated Rate |
$4,471.20 |
| Rate for Payer: Aetna Commercial |
$4,374.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,179.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,575.80
|
| Rate for Payer: Cash Price |
$1,458.00
|
| Rate for Payer: Cigna Commercial |
$4,471.20
|
| Rate for Payer: Health EOS Commercial |
$4,325.40
|
| Rate for Payer: HFN Commercial |
$4,471.20
|
| Rate for Payer: Multiplan Commercial |
$3,888.00
|
| Rate for Payer: NAPHCARE Commercial |
$2,916.00
|
| Rate for Payer: Preferred Network Access Commercial |
$4,471.20
|
| Rate for Payer: Quartz Beloit One Network |
$2,381.40
|
| Rate for Payer: Quartz Commercial |
$2,916.00
|
| Rate for Payer: WEA Trust Commercial |
$2,673.00
|
| Rate for Payer: WPS Commercial |
$3,599.80
|
|
|
SHELL BIPOLAR 43 MM 5001-43
|
Facility
|
OP
|
$4,860.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2967813
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,360.80 |
| Max. Negotiated Rate |
$19,440.00 |
| Rate for Payer: Aetna Commercial |
$4,374.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,179.60
|
| Rate for Payer: Aetna Managed Medicare |
$1,360.80
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,159.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,430.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,332.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,575.80
|
| Rate for Payer: Cash Price |
$1,458.00
|
| Rate for Payer: Cigna Commercial |
$4,471.20
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,719.66
|
| Rate for Payer: Health EOS Commercial |
$4,325.40
|
| Rate for Payer: HFN Commercial |
$4,471.20
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,645.00
|
| Rate for Payer: Multiplan Commercial |
$3,888.00
|
| Rate for Payer: NAPHCARE Commercial |
$2,916.00
|
| Rate for Payer: Preferred Network Access Commercial |
$4,471.20
|
| Rate for Payer: Quartz Beloit One Network |
$2,381.40
|
| Rate for Payer: Quartz Commercial |
$3,159.00
|
| Rate for Payer: Quartz Medicare Advantage |
$2,916.00
|
| Rate for Payer: The Alliance Commercial |
$19,440.00
|
| Rate for Payer: WEA Trust Commercial |
$2,673.00
|
| Rate for Payer: WPS Commercial |
$3,599.80
|
|
|
SHELL BIPOLAR 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: Aetna Gatekeeper/Not Gatekeeper |
$4,179.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,575.80
|
| Rate for Payer: Cash Price |
$1,458.00
|
| Rate for Payer: Cigna Commercial |
$4,471.20
|
| Rate for Payer: Health EOS Commercial |
$4,325.40
|
| Rate for Payer: HFN Commercial |
$4,471.20
|
| Rate for Payer: Multiplan Commercial |
$3,888.00
|
| Rate for Payer: NAPHCARE Commercial |
$2,916.00
|
| Rate for Payer: Preferred Network Access Commercial |
$4,471.20
|
| Rate for Payer: Quartz Beloit One Network |
$2,381.40
|
| Rate for Payer: Quartz Commercial |
$2,916.00
|
| Rate for Payer: WEA Trust Commercial |
$2,673.00
|
| Rate for Payer: WPS Commercial |
$3,599.80
|
|
|
SHELL BIPOLAR 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: Aetna Gatekeeper/Not Gatekeeper |
$4,179.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,575.80
|
| Rate for Payer: Cash Price |
$1,458.00
|
| Rate for Payer: Cigna Commercial |
$4,471.20
|
| Rate for Payer: Health EOS Commercial |
$4,325.40
|
| Rate for Payer: HFN Commercial |
$4,471.20
|
| Rate for Payer: Multiplan Commercial |
$3,888.00
|
| Rate for Payer: NAPHCARE Commercial |
$2,916.00
|
| Rate for Payer: Preferred Network Access Commercial |
$4,471.20
|
| Rate for Payer: Quartz Beloit One Network |
$2,381.40
|
| Rate for Payer: Quartz Commercial |
$2,916.00
|
| Rate for Payer: WEA Trust Commercial |
$2,673.00
|
| Rate for Payer: WPS Commercial |
$3,599.80
|
|
