|
STEM EXTEN 45MM DROP DOWN 5950-067-45
|
Facility
|
IP
|
$4,701.00
|
|
| Hospital Charge Code |
2967858
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,303.49 |
| Max. Negotiated Rate |
$4,324.92 |
| Rate for Payer: Aetna Commercial |
$4,230.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,042.86
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,491.53
|
| Rate for Payer: Cash Price |
$1,410.30
|
| Rate for Payer: Cigna Commercial |
$4,324.92
|
| Rate for Payer: Health EOS Commercial |
$4,183.89
|
| Rate for Payer: HFN Commercial |
$4,324.92
|
| Rate for Payer: Multiplan Commercial |
$3,760.80
|
| Rate for Payer: NAPHCARE Commercial |
$2,820.60
|
| Rate for Payer: Preferred Network Access Commercial |
$4,324.92
|
| Rate for Payer: Quartz Beloit One Network |
$2,303.49
|
| Rate for Payer: Quartz Commercial |
$2,820.60
|
| Rate for Payer: WEA Trust Commercial |
$2,585.55
|
| Rate for Payer: WPS Commercial |
$3,482.03
|
|
|
STEM EXTEN 45MM DROP DOWN 5950-067-45
|
Facility
|
OP
|
$4,701.00
|
|
| Hospital Charge Code |
2967858
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,316.28 |
| Max. Negotiated Rate |
$18,804.00 |
| Rate for Payer: Aetna Commercial |
$4,230.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,042.86
|
| Rate for Payer: Aetna Managed Medicare |
$1,316.28
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,055.65
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,350.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,256.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,491.53
|
| Rate for Payer: Cash Price |
$1,410.30
|
| Rate for Payer: Cigna Commercial |
$4,324.92
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,630.68
|
| Rate for Payer: Health EOS Commercial |
$4,183.89
|
| Rate for Payer: HFN Commercial |
$4,324.92
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,525.75
|
| Rate for Payer: Multiplan Commercial |
$3,760.80
|
| Rate for Payer: NAPHCARE Commercial |
$2,820.60
|
| Rate for Payer: Preferred Network Access Commercial |
$4,324.92
|
| Rate for Payer: Quartz Beloit One Network |
$2,303.49
|
| Rate for Payer: Quartz Commercial |
$3,055.65
|
| Rate for Payer: Quartz Medicare Advantage |
$2,820.60
|
| Rate for Payer: The Alliance Commercial |
$18,804.00
|
| Rate for Payer: WEA Trust Commercial |
$2,585.55
|
| Rate for Payer: WPS Commercial |
$3,482.03
|
|
|
STEM EXTEN 75MM DROP DOWN 5950-67-75
|
Facility
|
OP
|
$4,701.00
|
|
| Hospital Charge Code |
2967859
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,316.28 |
| Max. Negotiated Rate |
$18,804.00 |
| Rate for Payer: Aetna Commercial |
$4,230.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,042.86
|
| Rate for Payer: Aetna Managed Medicare |
$1,316.28
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,055.65
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,350.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,256.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,491.53
|
| Rate for Payer: Cash Price |
$1,410.30
|
| Rate for Payer: Cigna Commercial |
$4,324.92
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,630.68
|
| Rate for Payer: Health EOS Commercial |
$4,183.89
|
| Rate for Payer: HFN Commercial |
$4,324.92
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,525.75
|
| Rate for Payer: Multiplan Commercial |
$3,760.80
|
| Rate for Payer: NAPHCARE Commercial |
$2,820.60
|
| Rate for Payer: Preferred Network Access Commercial |
$4,324.92
|
| Rate for Payer: Quartz Beloit One Network |
$2,303.49
|
| Rate for Payer: Quartz Commercial |
$3,055.65
|
| Rate for Payer: Quartz Medicare Advantage |
$2,820.60
|
| Rate for Payer: The Alliance Commercial |
$18,804.00
|
| Rate for Payer: WEA Trust Commercial |
$2,585.55
|
| Rate for Payer: WPS Commercial |
$3,482.03
|
|
|
STEM EXTEN 75MM DROP DOWN 5950-67-75
|
Facility
|
IP
|
$4,701.00
|
|
| Hospital Charge Code |
2967859
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,303.49 |
| Max. Negotiated Rate |
$4,324.92 |
| Rate for Payer: Aetna Commercial |
$4,230.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,042.86
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,491.53
|
| Rate for Payer: Cash Price |
$1,410.30
|
| Rate for Payer: Cigna Commercial |
$4,324.92
|
| Rate for Payer: Health EOS Commercial |
$4,183.89
|
| Rate for Payer: HFN Commercial |
$4,324.92
|
| Rate for Payer: Multiplan Commercial |
$3,760.80
|
| Rate for Payer: NAPHCARE Commercial |
$2,820.60
|
| Rate for Payer: Preferred Network Access Commercial |
$4,324.92
|
| Rate for Payer: Quartz Beloit One Network |
$2,303.49
|
| Rate for Payer: Quartz Commercial |
$2,820.60
|
| Rate for Payer: WEA Trust Commercial |
$2,585.55
|
| Rate for Payer: WPS Commercial |
$3,482.03
|
|
|
STEM EXTENSION 12m x 100mm
|
Facility
|
OP
|
$7,810.00
|
|
| Hospital Charge Code |
2967533
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,186.80 |
| Max. Negotiated Rate |
$31,240.00 |
| Rate for Payer: Aetna Commercial |
$7,029.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,716.60
|
| Rate for Payer: Aetna Managed Medicare |
$2,186.80
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5,076.50
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,905.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,748.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,139.30
|
| Rate for Payer: Cash Price |
$2,343.00
|
| Rate for Payer: Cigna Commercial |
$7,185.20
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,370.48
|
| Rate for Payer: Health EOS Commercial |
$6,950.90
|
| Rate for Payer: HFN Commercial |
$7,185.20
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5,857.50
|
| Rate for Payer: Multiplan Commercial |
$6,248.00
|
| Rate for Payer: NAPHCARE Commercial |
$4,686.00
|
| Rate for Payer: Preferred Network Access Commercial |
$7,185.20
|
| Rate for Payer: Quartz Beloit One Network |
$3,826.90
|
| Rate for Payer: Quartz Commercial |
$5,076.50
|
| Rate for Payer: Quartz Medicare Advantage |
$4,686.00
|
| Rate for Payer: The Alliance Commercial |
$31,240.00
|
| Rate for Payer: WEA Trust Commercial |
$4,295.50
|
| Rate for Payer: WPS Commercial |
$5,784.87
|
|
|
STEM EXTENSION 12m x 100mm
|
Facility
|
IP
|
$7,810.00
|
|
| Hospital Charge Code |
2967533
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,826.90 |
| Max. Negotiated Rate |
$7,185.20 |
| Rate for Payer: Aetna Commercial |
$7,029.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,716.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,139.30
|
| Rate for Payer: Cash Price |
$2,343.00
|
| Rate for Payer: Cigna Commercial |
$7,185.20
|
| Rate for Payer: Health EOS Commercial |
$6,950.90
|
| Rate for Payer: HFN Commercial |
$7,185.20
|
| Rate for Payer: Multiplan Commercial |
$6,248.00
|
| Rate for Payer: NAPHCARE Commercial |
$4,686.00
|
| Rate for Payer: Preferred Network Access Commercial |
$7,185.20
|
| Rate for Payer: Quartz Beloit One Network |
$3,826.90
|
| Rate for Payer: Quartz Commercial |
$4,686.00
|
| Rate for Payer: WEA Trust Commercial |
$4,295.50
|
| Rate for Payer: WPS Commercial |
$5,784.87
|
|
|
STEM EXTENSION FLUTED 11MM X 75MM 00-5988-015-11
|
Facility
|
OP
|
$5,067.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
6192970
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,418.76 |
| Max. Negotiated Rate |
$20,268.00 |
| Rate for Payer: Aetna Commercial |
$4,560.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,357.62
|
| Rate for Payer: Aetna Managed Medicare |
$1,418.76
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,293.55
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,533.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,432.16
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,685.51
|
| Rate for Payer: Cash Price |
$1,520.10
|
| Rate for Payer: Cigna Commercial |
$4,661.64
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,835.49
|
| Rate for Payer: Health EOS Commercial |
$4,509.63
|
| Rate for Payer: HFN Commercial |
$4,661.64
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,800.25
|
| Rate for Payer: Multiplan Commercial |
$4,053.60
|
| Rate for Payer: NAPHCARE Commercial |
$3,040.20
|
| Rate for Payer: Preferred Network Access Commercial |
$4,661.64
|
| Rate for Payer: Quartz Beloit One Network |
$2,482.83
|
| Rate for Payer: Quartz Commercial |
$3,293.55
|
| Rate for Payer: Quartz Medicare Advantage |
$3,040.20
|
| Rate for Payer: The Alliance Commercial |
$20,268.00
|
| Rate for Payer: WEA Trust Commercial |
$2,786.85
|
| Rate for Payer: WPS Commercial |
$3,753.13
|
|
|
STEM EXTENSION FLUTED 11MM X 75MM 00-5988-015-11
|
Facility
|
IP
|
$5,067.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
6192970
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,482.83 |
| Max. Negotiated Rate |
$4,661.64 |
| Rate for Payer: Aetna Commercial |
$4,560.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,357.62
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,685.51
|
| Rate for Payer: Cash Price |
$1,520.10
|
| Rate for Payer: Cigna Commercial |
$4,661.64
|
| Rate for Payer: Health EOS Commercial |
$4,509.63
|
| Rate for Payer: HFN Commercial |
$4,661.64
|
| Rate for Payer: Multiplan Commercial |
$4,053.60
|
| Rate for Payer: NAPHCARE Commercial |
$3,040.20
|
| Rate for Payer: Preferred Network Access Commercial |
$4,661.64
|
| Rate for Payer: Quartz Beloit One Network |
$2,482.83
|
| Rate for Payer: Quartz Commercial |
$3,040.20
|
| Rate for Payer: WEA Trust Commercial |
$2,786.85
|
| Rate for Payer: WPS Commercial |
$3,753.13
|
|
|
STEM EXTENSION FLUTED 13MM X 130MM 00-5988-016-13
|
Facility
|
IP
|
$5,067.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
6192964
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,482.83 |
| Max. Negotiated Rate |
$4,661.64 |
| Rate for Payer: Aetna Commercial |
$4,560.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,357.62
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,685.51
|
| Rate for Payer: Cash Price |
$1,520.10
|
| Rate for Payer: Cigna Commercial |
$4,661.64
|
| Rate for Payer: Health EOS Commercial |
$4,509.63
|
| Rate for Payer: HFN Commercial |
$4,661.64
|
| Rate for Payer: Multiplan Commercial |
$4,053.60
|
| Rate for Payer: NAPHCARE Commercial |
$3,040.20
|
| Rate for Payer: Preferred Network Access Commercial |
$4,661.64
|
| Rate for Payer: Quartz Beloit One Network |
$2,482.83
|
| Rate for Payer: Quartz Commercial |
$3,040.20
|
| Rate for Payer: WEA Trust Commercial |
$2,786.85
|
| Rate for Payer: WPS Commercial |
$3,753.13
|
|
|
STEM EXTENSION FLUTED 13MM X 130MM 00-5988-016-13
|
Facility
|
OP
|
$5,067.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
6192964
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,418.76 |
| Max. Negotiated Rate |
$20,268.00 |
| Rate for Payer: Aetna Commercial |
$4,560.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,357.62
|
| Rate for Payer: Aetna Managed Medicare |
$1,418.76
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,293.55
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,533.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,432.16
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,685.51
|
| Rate for Payer: Cash Price |
$1,520.10
|
| Rate for Payer: Cigna Commercial |
$4,661.64
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,835.49
|
| Rate for Payer: Health EOS Commercial |
$4,509.63
|
| Rate for Payer: HFN Commercial |
$4,661.64
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,800.25
|
| Rate for Payer: Multiplan Commercial |
$4,053.60
|
| Rate for Payer: NAPHCARE Commercial |
$3,040.20
|
| Rate for Payer: Preferred Network Access Commercial |
$4,661.64
|
| Rate for Payer: Quartz Beloit One Network |
$2,482.83
|
| Rate for Payer: Quartz Commercial |
$3,293.55
|
| Rate for Payer: Quartz Medicare Advantage |
$3,040.20
|
| Rate for Payer: The Alliance Commercial |
$20,268.00
|
| Rate for Payer: WEA Trust Commercial |
$2,786.85
|
| Rate for Payer: WPS Commercial |
$3,753.13
|
|
|
STEM EXTENSION OFFSET 11MM X 100MM 5988-20-11
|
Facility
|
OP
|
$7,651.00
|
|
| Hospital Charge Code |
2973971
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,142.28 |
| Max. Negotiated Rate |
$30,604.00 |
| Rate for Payer: Aetna Commercial |
$6,885.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,579.86
|
| Rate for Payer: Aetna Managed Medicare |
$2,142.28
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,973.15
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,825.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,672.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,055.03
|
| Rate for Payer: Cash Price |
$2,295.30
|
| Rate for Payer: Cigna Commercial |
$7,038.92
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,281.50
|
| Rate for Payer: Health EOS Commercial |
$6,809.39
|
| Rate for Payer: HFN Commercial |
$7,038.92
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5,738.25
|
| Rate for Payer: Multiplan Commercial |
$6,120.80
|
| Rate for Payer: NAPHCARE Commercial |
$4,590.60
|
| Rate for Payer: Preferred Network Access Commercial |
$7,038.92
|
| Rate for Payer: Quartz Beloit One Network |
$3,748.99
|
| Rate for Payer: Quartz Commercial |
$4,973.15
|
| Rate for Payer: Quartz Medicare Advantage |
$4,590.60
|
| Rate for Payer: The Alliance Commercial |
$30,604.00
|
| Rate for Payer: WEA Trust Commercial |
$4,208.05
|
| Rate for Payer: WPS Commercial |
$5,667.10
|
|
|
STEM EXTENSION OFFSET 11MM X 100MM 5988-20-11
|
Facility
|
IP
|
$7,651.00
|
|
| Hospital Charge Code |
2973971
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,748.99 |
| Max. Negotiated Rate |
$7,038.92 |
| Rate for Payer: Aetna Commercial |
$6,885.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,579.86
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,055.03
|
| Rate for Payer: Cash Price |
$2,295.30
|
| Rate for Payer: Cigna Commercial |
$7,038.92
|
| Rate for Payer: Health EOS Commercial |
$6,809.39
|
| Rate for Payer: HFN Commercial |
$7,038.92
|
| Rate for Payer: Multiplan Commercial |
$6,120.80
|
| Rate for Payer: NAPHCARE Commercial |
$4,590.60
|
| Rate for Payer: Preferred Network Access Commercial |
$7,038.92
|
| Rate for Payer: Quartz Beloit One Network |
$3,748.99
|
| Rate for Payer: Quartz Commercial |
$4,590.60
|
| Rate for Payer: WEA Trust Commercial |
$4,208.05
|
| Rate for Payer: WPS Commercial |
$5,667.10
|
|
|
STEM EXTENSION OFFSET 13MM X 100MM 5988-20-13
|
Facility
|
IP
|
$7,651.00
|
|
| Hospital Charge Code |
2973977
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,748.99 |
| Max. Negotiated Rate |
$7,038.92 |
| Rate for Payer: Aetna Commercial |
$6,885.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,579.86
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,055.03
|
| Rate for Payer: Cash Price |
$2,295.30
|
| Rate for Payer: Cigna Commercial |
$7,038.92
|
| Rate for Payer: Health EOS Commercial |
$6,809.39
|
| Rate for Payer: HFN Commercial |
$7,038.92
|
| Rate for Payer: Multiplan Commercial |
$6,120.80
|
| Rate for Payer: NAPHCARE Commercial |
$4,590.60
|
| Rate for Payer: Preferred Network Access Commercial |
$7,038.92
|
| Rate for Payer: Quartz Beloit One Network |
$3,748.99
|
| Rate for Payer: Quartz Commercial |
$4,590.60
|
| Rate for Payer: WEA Trust Commercial |
$4,208.05
|
| Rate for Payer: WPS Commercial |
$5,667.10
|
|
|
STEM EXTENSION OFFSET 13MM X 100MM 5988-20-13
|
Facility
|
OP
|
$7,651.00
|
|
| Hospital Charge Code |
2973977
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,142.28 |
| Max. Negotiated Rate |
$30,604.00 |
| Rate for Payer: Aetna Commercial |
$6,885.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,579.86
|
| Rate for Payer: Aetna Managed Medicare |
$2,142.28
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,973.15
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,825.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,672.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,055.03
|
| Rate for Payer: Cash Price |
$2,295.30
|
| Rate for Payer: Cigna Commercial |
$7,038.92
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,281.50
|
| Rate for Payer: Health EOS Commercial |
$6,809.39
|
| Rate for Payer: HFN Commercial |
$7,038.92
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5,738.25
|
| Rate for Payer: Multiplan Commercial |
$6,120.80
|
| Rate for Payer: NAPHCARE Commercial |
$4,590.60
|
| Rate for Payer: Preferred Network Access Commercial |
$7,038.92
|
| Rate for Payer: Quartz Beloit One Network |
$3,748.99
|
| Rate for Payer: Quartz Commercial |
$4,973.15
|
| Rate for Payer: Quartz Medicare Advantage |
$4,590.60
|
| Rate for Payer: The Alliance Commercial |
$30,604.00
|
| Rate for Payer: WEA Trust Commercial |
$4,208.05
|
| Rate for Payer: WPS Commercial |
$5,667.10
|
|
|
STEM EXTENSION OFFSET 15MM X 100MM 5988-20-15
|
Facility
|
OP
|
$7,651.00
|
|
| Hospital Charge Code |
2973972
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,142.28 |
| Max. Negotiated Rate |
$30,604.00 |
| Rate for Payer: Aetna Commercial |
$6,885.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,579.86
|
| Rate for Payer: Aetna Managed Medicare |
$2,142.28
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,973.15
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,825.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,672.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,055.03
|
| Rate for Payer: Cash Price |
$2,295.30
|
| Rate for Payer: Cigna Commercial |
$7,038.92
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,281.50
|
| Rate for Payer: Health EOS Commercial |
$6,809.39
|
| Rate for Payer: HFN Commercial |
$7,038.92
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5,738.25
|
| Rate for Payer: Multiplan Commercial |
$6,120.80
|
| Rate for Payer: NAPHCARE Commercial |
$4,590.60
|
| Rate for Payer: Preferred Network Access Commercial |
$7,038.92
|
| Rate for Payer: Quartz Beloit One Network |
$3,748.99
|
| Rate for Payer: Quartz Commercial |
$4,973.15
|
| Rate for Payer: Quartz Medicare Advantage |
$4,590.60
|
| Rate for Payer: The Alliance Commercial |
$30,604.00
|
| Rate for Payer: WEA Trust Commercial |
$4,208.05
|
| Rate for Payer: WPS Commercial |
$5,667.10
|
|
|
STEM EXTENSION OFFSET 15MM X 100MM 5988-20-15
|
Facility
|
IP
|
$7,651.00
|
|
| Hospital Charge Code |
2973972
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,748.99 |
| Max. Negotiated Rate |
$7,038.92 |
| Rate for Payer: Aetna Commercial |
$6,885.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,579.86
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,055.03
|
| Rate for Payer: Cash Price |
$2,295.30
|
| Rate for Payer: Cigna Commercial |
$7,038.92
|
| Rate for Payer: Health EOS Commercial |
$6,809.39
|
| Rate for Payer: HFN Commercial |
$7,038.92
|
| Rate for Payer: Multiplan Commercial |
$6,120.80
|
| Rate for Payer: NAPHCARE Commercial |
$4,590.60
|
| Rate for Payer: Preferred Network Access Commercial |
$7,038.92
|
| Rate for Payer: Quartz Beloit One Network |
$3,748.99
|
| Rate for Payer: Quartz Commercial |
$4,590.60
|
| Rate for Payer: WEA Trust Commercial |
$4,208.05
|
| Rate for Payer: WPS Commercial |
$5,667.10
|
|
|
STEM EXTENSION STR 10 x 145mm
|
Facility
|
IP
|
$8,784.00
|
|
| Hospital Charge Code |
2974040
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,304.16 |
| Max. Negotiated Rate |
$8,081.28 |
| Rate for Payer: Aetna Commercial |
$7,905.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,554.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,655.52
|
| Rate for Payer: Cash Price |
$2,635.20
|
| Rate for Payer: Cigna Commercial |
$8,081.28
|
| Rate for Payer: Health EOS Commercial |
$7,817.76
|
| Rate for Payer: HFN Commercial |
$8,081.28
|
| Rate for Payer: Multiplan Commercial |
$7,027.20
|
| Rate for Payer: NAPHCARE Commercial |
$5,270.40
|
| Rate for Payer: Preferred Network Access Commercial |
$8,081.28
|
| Rate for Payer: Quartz Beloit One Network |
$4,304.16
|
| Rate for Payer: Quartz Commercial |
$5,270.40
|
| Rate for Payer: WEA Trust Commercial |
$4,831.20
|
| Rate for Payer: WPS Commercial |
$6,506.31
|
|
|
STEM EXTENSION STR 10 x 145mm
|
Facility
|
OP
|
$8,784.00
|
|
| Hospital Charge Code |
2974040
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,459.52 |
| Max. Negotiated Rate |
$35,136.00 |
| Rate for Payer: Aetna Commercial |
$7,905.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,554.24
|
| Rate for Payer: Aetna Managed Medicare |
$2,459.52
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5,709.60
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,392.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,216.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,655.52
|
| Rate for Payer: Cash Price |
$2,635.20
|
| Rate for Payer: Cigna Commercial |
$8,081.28
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,915.53
|
| Rate for Payer: Health EOS Commercial |
$7,817.76
|
| Rate for Payer: HFN Commercial |
$8,081.28
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$6,588.00
|
| Rate for Payer: Multiplan Commercial |
$7,027.20
|
| Rate for Payer: NAPHCARE Commercial |
$5,270.40
|
| Rate for Payer: Preferred Network Access Commercial |
$8,081.28
|
| Rate for Payer: Quartz Beloit One Network |
$4,304.16
|
| Rate for Payer: Quartz Commercial |
$5,709.60
|
| Rate for Payer: Quartz Medicare Advantage |
$5,270.40
|
| Rate for Payer: The Alliance Commercial |
$35,136.00
|
| Rate for Payer: WEA Trust Commercial |
$4,831.20
|
| Rate for Payer: WPS Commercial |
$6,506.31
|
|
|
STEM EXTENSION STR 11MM X 100MM 5988-10-11
|
Facility
|
OP
|
$8,784.00
|
|
| Hospital Charge Code |
2967535
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,459.52 |
| Max. Negotiated Rate |
$35,136.00 |
| Rate for Payer: Aetna Commercial |
$7,905.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,554.24
|
| Rate for Payer: Aetna Managed Medicare |
$2,459.52
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5,709.60
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,392.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,216.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,655.52
|
| Rate for Payer: Cash Price |
$2,635.20
|
| Rate for Payer: Cigna Commercial |
$8,081.28
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,915.53
|
| Rate for Payer: Health EOS Commercial |
$7,817.76
|
| Rate for Payer: HFN Commercial |
$8,081.28
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$6,588.00
|
| Rate for Payer: Multiplan Commercial |
$7,027.20
|
| Rate for Payer: NAPHCARE Commercial |
$5,270.40
|
| Rate for Payer: Preferred Network Access Commercial |
$8,081.28
|
| Rate for Payer: Quartz Beloit One Network |
$4,304.16
|
| Rate for Payer: Quartz Commercial |
$5,709.60
|
| Rate for Payer: Quartz Medicare Advantage |
$5,270.40
|
| Rate for Payer: The Alliance Commercial |
$35,136.00
|
| Rate for Payer: WEA Trust Commercial |
$4,831.20
|
| Rate for Payer: WPS Commercial |
$6,506.31
|
|
|
STEM EXTENSION STR 11MM X 100MM 5988-10-11
|
Facility
|
IP
|
$8,784.00
|
|
| Hospital Charge Code |
2967535
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,304.16 |
| Max. Negotiated Rate |
$8,081.28 |
| Rate for Payer: Aetna Commercial |
$7,905.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,554.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,655.52
|
| Rate for Payer: Cash Price |
$2,635.20
|
| Rate for Payer: Cigna Commercial |
$8,081.28
|
| Rate for Payer: Health EOS Commercial |
$7,817.76
|
| Rate for Payer: HFN Commercial |
$8,081.28
|
| Rate for Payer: Multiplan Commercial |
$7,027.20
|
| Rate for Payer: NAPHCARE Commercial |
$5,270.40
|
| Rate for Payer: Preferred Network Access Commercial |
$8,081.28
|
| Rate for Payer: Quartz Beloit One Network |
$4,304.16
|
| Rate for Payer: Quartz Commercial |
$5,270.40
|
| Rate for Payer: WEA Trust Commercial |
$4,831.20
|
| Rate for Payer: WPS Commercial |
$6,506.31
|
|
|
STEM EXTENSION STR 13MM x 100MM 5988-10-13
|
Facility
|
IP
|
$8,784.00
|
|
| Hospital Charge Code |
2973974
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,304.16 |
| Max. Negotiated Rate |
$8,081.28 |
| Rate for Payer: Aetna Commercial |
$7,905.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,554.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,655.52
|
| Rate for Payer: Cash Price |
$2,635.20
|
| Rate for Payer: Cigna Commercial |
$8,081.28
|
| Rate for Payer: Health EOS Commercial |
$7,817.76
|
| Rate for Payer: HFN Commercial |
$8,081.28
|
| Rate for Payer: Multiplan Commercial |
$7,027.20
|
| Rate for Payer: NAPHCARE Commercial |
$5,270.40
|
| Rate for Payer: Preferred Network Access Commercial |
$8,081.28
|
| Rate for Payer: Quartz Beloit One Network |
$4,304.16
|
| Rate for Payer: Quartz Commercial |
$5,270.40
|
| Rate for Payer: WEA Trust Commercial |
$4,831.20
|
| Rate for Payer: WPS Commercial |
$6,506.31
|
|
|
STEM EXTENSION STR 13MM x 100MM 5988-10-13
|
Facility
|
OP
|
$8,784.00
|
|
| Hospital Charge Code |
2973974
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,459.52 |
| Max. Negotiated Rate |
$35,136.00 |
| Rate for Payer: Aetna Commercial |
$7,905.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,554.24
|
| Rate for Payer: Aetna Managed Medicare |
$2,459.52
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5,709.60
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,392.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,216.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,655.52
|
| Rate for Payer: Cash Price |
$2,635.20
|
| Rate for Payer: Cigna Commercial |
$8,081.28
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,915.53
|
| Rate for Payer: Health EOS Commercial |
$7,817.76
|
| Rate for Payer: HFN Commercial |
$8,081.28
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$6,588.00
|
| Rate for Payer: Multiplan Commercial |
$7,027.20
|
| Rate for Payer: NAPHCARE Commercial |
$5,270.40
|
| Rate for Payer: Preferred Network Access Commercial |
$8,081.28
|
| Rate for Payer: Quartz Beloit One Network |
$4,304.16
|
| Rate for Payer: Quartz Commercial |
$5,709.60
|
| Rate for Payer: Quartz Medicare Advantage |
$5,270.40
|
| Rate for Payer: The Alliance Commercial |
$35,136.00
|
| Rate for Payer: WEA Trust Commercial |
$4,831.20
|
| Rate for Payer: WPS Commercial |
$6,506.31
|
|
|
STEM EXTENSION STR 15MM X 100MM 5988-10-15
|
Facility
|
OP
|
$8,784.00
|
|
| Hospital Charge Code |
2973970
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,459.52 |
| Max. Negotiated Rate |
$35,136.00 |
| Rate for Payer: Aetna Commercial |
$7,905.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,554.24
|
| Rate for Payer: Aetna Managed Medicare |
$2,459.52
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5,709.60
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,392.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,216.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,655.52
|
| Rate for Payer: Cash Price |
$2,635.20
|
| Rate for Payer: Cigna Commercial |
$8,081.28
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,915.53
|
| Rate for Payer: Health EOS Commercial |
$7,817.76
|
| Rate for Payer: HFN Commercial |
$8,081.28
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$6,588.00
|
| Rate for Payer: Multiplan Commercial |
$7,027.20
|
| Rate for Payer: NAPHCARE Commercial |
$5,270.40
|
| Rate for Payer: Preferred Network Access Commercial |
$8,081.28
|
| Rate for Payer: Quartz Beloit One Network |
$4,304.16
|
| Rate for Payer: Quartz Commercial |
$5,709.60
|
| Rate for Payer: Quartz Medicare Advantage |
$5,270.40
|
| Rate for Payer: The Alliance Commercial |
$35,136.00
|
| Rate for Payer: WEA Trust Commercial |
$4,831.20
|
| Rate for Payer: WPS Commercial |
$6,506.31
|
|
|
STEM EXTENSION STR 15MM X 100MM 5988-10-15
|
Facility
|
IP
|
$8,784.00
|
|
| Hospital Charge Code |
2973970
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,304.16 |
| Max. Negotiated Rate |
$8,081.28 |
| Rate for Payer: Aetna Commercial |
$7,905.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,554.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,655.52
|
| Rate for Payer: Cash Price |
$2,635.20
|
| Rate for Payer: Cigna Commercial |
$8,081.28
|
| Rate for Payer: Health EOS Commercial |
$7,817.76
|
| Rate for Payer: HFN Commercial |
$8,081.28
|
| Rate for Payer: Multiplan Commercial |
$7,027.20
|
| Rate for Payer: NAPHCARE Commercial |
$5,270.40
|
| Rate for Payer: Preferred Network Access Commercial |
$8,081.28
|
| Rate for Payer: Quartz Beloit One Network |
$4,304.16
|
| Rate for Payer: Quartz Commercial |
$5,270.40
|
| Rate for Payer: WEA Trust Commercial |
$4,831.20
|
| Rate for Payer: WPS Commercial |
$6,506.31
|
|
|
STEM EXTENSION STR 15MM X 30MM 5988-12-15
|
Facility
|
IP
|
$8,784.00
|
|
| Hospital Charge Code |
2973969
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,304.16 |
| Max. Negotiated Rate |
$8,081.28 |
| Rate for Payer: Aetna Commercial |
$7,905.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,554.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,655.52
|
| Rate for Payer: Cash Price |
$2,635.20
|
| Rate for Payer: Cigna Commercial |
$8,081.28
|
| Rate for Payer: Health EOS Commercial |
$7,817.76
|
| Rate for Payer: HFN Commercial |
$8,081.28
|
| Rate for Payer: Multiplan Commercial |
$7,027.20
|
| Rate for Payer: NAPHCARE Commercial |
$5,270.40
|
| Rate for Payer: Preferred Network Access Commercial |
$8,081.28
|
| Rate for Payer: Quartz Beloit One Network |
$4,304.16
|
| Rate for Payer: Quartz Commercial |
$5,270.40
|
| Rate for Payer: WEA Trust Commercial |
$4,831.20
|
| Rate for Payer: WPS Commercial |
$6,506.31
|
|
