|
COMPONENT FEM E-LT TI-NIDIUM 00-5968-015-51COMPONENT FEM E-LT TI-NIDIUM 00-5968-015-51
|
Facility
|
IP
|
$24,212.00
|
|
| Hospital Charge Code |
2967455
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$12,338.44 |
| Max. Negotiated Rate |
$23,166.04 |
| Rate for Payer: Aetna Commercial |
$22,662.43
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$21,655.21
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$13,345.65
|
| Rate for Payer: Cash Price |
$7,263.60
|
| Rate for Payer: Cigna Commercial |
$23,166.04
|
| Rate for Payer: Health EOS Commercial |
$22,410.63
|
| Rate for Payer: HFN Commercial |
$23,166.04
|
| Rate for Payer: Multiplan Commercial |
$20,144.38
|
| Rate for Payer: Preferred Network Access Commercial |
$23,166.04
|
| Rate for Payer: Quartz Beloit One Network |
$12,338.44
|
| Rate for Payer: Quartz Commercial |
$15,108.29
|
| Rate for Payer: WEA Trust Commercial |
$13,849.26
|
| Rate for Payer: WPS Commercial |
$18,650.50
|
|
|
COMPONENT FEM E-LT TI-NIDIUM 00-5968-015-51COMPONENT FEM E-LT TI-NIDIUM 00-5968-015-51
|
Facility
|
OP
|
$24,212.00
|
|
| Hospital Charge Code |
2967455
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$7,050.53 |
| Max. Negotiated Rate |
$23,166.04 |
| Rate for Payer: Aetna Commercial |
$22,662.43
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$21,655.21
|
| Rate for Payer: Aetna Managed Medicare |
$7,050.53
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$16,367.31
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$12,590.24
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$12,086.63
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$13,345.65
|
| Rate for Payer: Cash Price |
$7,263.60
|
| Rate for Payer: Cigna Commercial |
$23,166.04
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$14,091.38
|
| Rate for Payer: Health EOS Commercial |
$22,410.63
|
| Rate for Payer: HFN Commercial |
$23,166.04
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$18,885.36
|
| Rate for Payer: Multiplan Commercial |
$20,144.38
|
| Rate for Payer: NAPHCARE Commercial |
$15,108.29
|
| Rate for Payer: Preferred Network Access Commercial |
$23,166.04
|
| Rate for Payer: Quartz Beloit One Network |
$12,338.44
|
| Rate for Payer: Quartz Commercial |
$16,367.31
|
| Rate for Payer: Quartz Medicare Advantage |
$15,108.29
|
| Rate for Payer: The Alliance Commercial |
$12,590.24
|
| Rate for Payer: WEA Trust Commercial |
$13,849.26
|
| Rate for Payer: WPS Commercial |
$18,650.50
|
|
|
COMPONENT FEM E-MINUS LT FLEX CR 5950-15-05
|
Facility
|
IP
|
$18,600.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2967658
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$9,478.56 |
| Max. Negotiated Rate |
$17,796.48 |
| Rate for Payer: Aetna Commercial |
$17,409.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$16,635.84
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$10,252.32
|
| Rate for Payer: Cash Price |
$5,580.00
|
| Rate for Payer: Cigna Commercial |
$17,796.48
|
| Rate for Payer: Health EOS Commercial |
$17,216.16
|
| Rate for Payer: HFN Commercial |
$17,796.48
|
| Rate for Payer: Multiplan Commercial |
$15,475.20
|
| Rate for Payer: Preferred Network Access Commercial |
$17,796.48
|
| Rate for Payer: Quartz Beloit One Network |
$9,478.56
|
| Rate for Payer: Quartz Commercial |
$11,606.40
|
| Rate for Payer: WEA Trust Commercial |
$10,639.20
|
| Rate for Payer: WPS Commercial |
$14,327.58
|
|
|
COMPONENT FEM E-MINUS LT FLEX CR 5950-15-05
|
Facility
|
OP
|
$18,600.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2967658
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,416.32 |
| Max. Negotiated Rate |
$17,796.48 |
| Rate for Payer: Aetna Commercial |
$17,409.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$16,635.84
|
| Rate for Payer: Aetna Managed Medicare |
$5,416.32
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$12,573.60
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$9,672.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$9,285.12
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$10,252.32
|
| Rate for Payer: Cash Price |
$5,580.00
|
| Rate for Payer: Cigna Commercial |
$17,796.48
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$10,825.20
|
| Rate for Payer: Health EOS Commercial |
$17,216.16
|
| Rate for Payer: HFN Commercial |
$17,796.48
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$14,508.00
|
| Rate for Payer: Multiplan Commercial |
$15,475.20
|
| Rate for Payer: NAPHCARE Commercial |
$11,606.40
|
| Rate for Payer: Preferred Network Access Commercial |
$17,796.48
|
| Rate for Payer: Quartz Beloit One Network |
$9,478.56
|
| Rate for Payer: Quartz Commercial |
$12,573.60
|
| Rate for Payer: Quartz Medicare Advantage |
$11,606.40
|
| Rate for Payer: The Alliance Commercial |
$9,672.00
|
| Rate for Payer: WEA Trust Commercial |
$10,639.20
|
| Rate for Payer: WPS Commercial |
$14,327.58
|
|
|
COMPONENT FEM E-MINUS LT GSF FLEX CR 00-5750-015-05
|
Facility
|
IP
|
$17,969.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2967659
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$9,157.00 |
| Max. Negotiated Rate |
$17,192.74 |
| Rate for Payer: Aetna Commercial |
$16,818.98
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$16,071.47
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$9,904.51
|
| Rate for Payer: Cash Price |
$5,390.70
|
| Rate for Payer: Cigna Commercial |
$17,192.74
|
| Rate for Payer: Health EOS Commercial |
$16,632.11
|
| Rate for Payer: HFN Commercial |
$17,192.74
|
| Rate for Payer: Multiplan Commercial |
$14,950.21
|
| Rate for Payer: Preferred Network Access Commercial |
$17,192.74
|
| Rate for Payer: Quartz Beloit One Network |
$9,157.00
|
| Rate for Payer: Quartz Commercial |
$11,212.66
|
| Rate for Payer: WEA Trust Commercial |
$10,278.27
|
| Rate for Payer: WPS Commercial |
$13,841.52
|
|
|
COMPONENT FEM E-MINUS LT GSF FLEX CR 00-5750-015-05
|
Facility
|
OP
|
$17,969.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2967659
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,232.57 |
| Max. Negotiated Rate |
$17,192.74 |
| Rate for Payer: Aetna Commercial |
$16,818.98
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$16,071.47
|
| Rate for Payer: Aetna Managed Medicare |
$5,232.57
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$12,147.04
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$9,343.88
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$8,970.12
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$9,904.51
|
| Rate for Payer: Cash Price |
$5,390.70
|
| Rate for Payer: Cigna Commercial |
$17,192.74
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$10,457.96
|
| Rate for Payer: Health EOS Commercial |
$16,632.11
|
| Rate for Payer: HFN Commercial |
$17,192.74
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$14,015.82
|
| Rate for Payer: Multiplan Commercial |
$14,950.21
|
| Rate for Payer: NAPHCARE Commercial |
$11,212.66
|
| Rate for Payer: Preferred Network Access Commercial |
$17,192.74
|
| Rate for Payer: Quartz Beloit One Network |
$9,157.00
|
| Rate for Payer: Quartz Commercial |
$12,147.04
|
| Rate for Payer: Quartz Medicare Advantage |
$11,212.66
|
| Rate for Payer: The Alliance Commercial |
$9,343.88
|
| Rate for Payer: WEA Trust Commercial |
$10,278.27
|
| Rate for Payer: WPS Commercial |
$13,841.52
|
|
|
COMPONENT FEM E-MINUS RT FLEX CR 5950-15-06
|
Facility
|
IP
|
$18,600.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2967660
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$9,478.56 |
| Max. Negotiated Rate |
$17,796.48 |
| Rate for Payer: Aetna Commercial |
$17,409.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$16,635.84
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$10,252.32
|
| Rate for Payer: Cash Price |
$5,580.00
|
| Rate for Payer: Cigna Commercial |
$17,796.48
|
| Rate for Payer: Health EOS Commercial |
$17,216.16
|
| Rate for Payer: HFN Commercial |
$17,796.48
|
| Rate for Payer: Multiplan Commercial |
$15,475.20
|
| Rate for Payer: Preferred Network Access Commercial |
$17,796.48
|
| Rate for Payer: Quartz Beloit One Network |
$9,478.56
|
| Rate for Payer: Quartz Commercial |
$11,606.40
|
| Rate for Payer: WEA Trust Commercial |
$10,639.20
|
| Rate for Payer: WPS Commercial |
$14,327.58
|
|
|
COMPONENT FEM E-MINUS RT FLEX CR 5950-15-06
|
Facility
|
OP
|
$18,600.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2967660
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,416.32 |
| Max. Negotiated Rate |
$17,796.48 |
| Rate for Payer: Aetna Commercial |
$17,409.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$16,635.84
|
| Rate for Payer: Aetna Managed Medicare |
$5,416.32
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$12,573.60
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$9,672.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$9,285.12
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$10,252.32
|
| Rate for Payer: Cash Price |
$5,580.00
|
| Rate for Payer: Cigna Commercial |
$17,796.48
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$10,825.20
|
| Rate for Payer: Health EOS Commercial |
$17,216.16
|
| Rate for Payer: HFN Commercial |
$17,796.48
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$14,508.00
|
| Rate for Payer: Multiplan Commercial |
$15,475.20
|
| Rate for Payer: NAPHCARE Commercial |
$11,606.40
|
| Rate for Payer: Preferred Network Access Commercial |
$17,796.48
|
| Rate for Payer: Quartz Beloit One Network |
$9,478.56
|
| Rate for Payer: Quartz Commercial |
$12,573.60
|
| Rate for Payer: Quartz Medicare Advantage |
$11,606.40
|
| Rate for Payer: The Alliance Commercial |
$9,672.00
|
| Rate for Payer: WEA Trust Commercial |
$10,639.20
|
| Rate for Payer: WPS Commercial |
$14,327.58
|
|
|
COMPONENT FEM E-MINUS RT GSF FLEX CR 00-5750-015-06
|
Facility
|
IP
|
$17,969.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2967661
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$9,157.00 |
| Max. Negotiated Rate |
$17,192.74 |
| Rate for Payer: Aetna Commercial |
$16,818.98
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$16,071.47
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$9,904.51
|
| Rate for Payer: Cash Price |
$5,390.70
|
| Rate for Payer: Cigna Commercial |
$17,192.74
|
| Rate for Payer: Health EOS Commercial |
$16,632.11
|
| Rate for Payer: HFN Commercial |
$17,192.74
|
| Rate for Payer: Multiplan Commercial |
$14,950.21
|
| Rate for Payer: Preferred Network Access Commercial |
$17,192.74
|
| Rate for Payer: Quartz Beloit One Network |
$9,157.00
|
| Rate for Payer: Quartz Commercial |
$11,212.66
|
| Rate for Payer: WEA Trust Commercial |
$10,278.27
|
| Rate for Payer: WPS Commercial |
$13,841.52
|
|
|
COMPONENT FEM E-MINUS RT GSF FLEX CR 00-5750-015-06
|
Facility
|
OP
|
$17,969.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2967661
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,232.57 |
| Max. Negotiated Rate |
$17,192.74 |
| Rate for Payer: Aetna Commercial |
$16,818.98
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$16,071.47
|
| Rate for Payer: Aetna Managed Medicare |
$5,232.57
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$12,147.04
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$9,343.88
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$8,970.12
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$9,904.51
|
| Rate for Payer: Cash Price |
$5,390.70
|
| Rate for Payer: Cigna Commercial |
$17,192.74
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$10,457.96
|
| Rate for Payer: Health EOS Commercial |
$16,632.11
|
| Rate for Payer: HFN Commercial |
$17,192.74
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$14,015.82
|
| Rate for Payer: Multiplan Commercial |
$14,950.21
|
| Rate for Payer: NAPHCARE Commercial |
$11,212.66
|
| Rate for Payer: Preferred Network Access Commercial |
$17,192.74
|
| Rate for Payer: Quartz Beloit One Network |
$9,157.00
|
| Rate for Payer: Quartz Commercial |
$12,147.04
|
| Rate for Payer: Quartz Medicare Advantage |
$11,212.66
|
| Rate for Payer: The Alliance Commercial |
$9,343.88
|
| Rate for Payer: WEA Trust Commercial |
$10,278.27
|
| Rate for Payer: WPS Commercial |
$13,841.52
|
|
|
COMPONENT FEM E-RT FLEX CR PRECOAT 5950-15-02
|
Facility
|
IP
|
$18,600.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2967662
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$9,478.56 |
| Max. Negotiated Rate |
$17,796.48 |
| Rate for Payer: Aetna Commercial |
$17,409.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$16,635.84
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$10,252.32
|
| Rate for Payer: Cash Price |
$5,580.00
|
| Rate for Payer: Cigna Commercial |
$17,796.48
|
| Rate for Payer: Health EOS Commercial |
$17,216.16
|
| Rate for Payer: HFN Commercial |
$17,796.48
|
| Rate for Payer: Multiplan Commercial |
$15,475.20
|
| Rate for Payer: Preferred Network Access Commercial |
$17,796.48
|
| Rate for Payer: Quartz Beloit One Network |
$9,478.56
|
| Rate for Payer: Quartz Commercial |
$11,606.40
|
| Rate for Payer: WEA Trust Commercial |
$10,639.20
|
| Rate for Payer: WPS Commercial |
$14,327.58
|
|
|
COMPONENT FEM E-RT FLEX CR PRECOAT 5950-15-02
|
Facility
|
OP
|
$18,600.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2967662
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,416.32 |
| Max. Negotiated Rate |
$17,796.48 |
| Rate for Payer: Aetna Commercial |
$17,409.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$16,635.84
|
| Rate for Payer: Aetna Managed Medicare |
$5,416.32
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$12,573.60
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$9,672.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$9,285.12
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$10,252.32
|
| Rate for Payer: Cash Price |
$5,580.00
|
| Rate for Payer: Cigna Commercial |
$17,796.48
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$10,825.20
|
| Rate for Payer: Health EOS Commercial |
$17,216.16
|
| Rate for Payer: HFN Commercial |
$17,796.48
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$14,508.00
|
| Rate for Payer: Multiplan Commercial |
$15,475.20
|
| Rate for Payer: NAPHCARE Commercial |
$11,606.40
|
| Rate for Payer: Preferred Network Access Commercial |
$17,796.48
|
| Rate for Payer: Quartz Beloit One Network |
$9,478.56
|
| Rate for Payer: Quartz Commercial |
$12,573.60
|
| Rate for Payer: Quartz Medicare Advantage |
$11,606.40
|
| Rate for Payer: The Alliance Commercial |
$9,672.00
|
| Rate for Payer: WEA Trust Commercial |
$10,639.20
|
| Rate for Payer: WPS Commercial |
$14,327.58
|
|
|
COMPONENT FEM E-RT GSF FLEX CR 00-5750-015-02
|
Facility
|
OP
|
$17,969.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2967663
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,232.57 |
| Max. Negotiated Rate |
$17,192.74 |
| Rate for Payer: Aetna Commercial |
$16,818.98
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$16,071.47
|
| Rate for Payer: Aetna Managed Medicare |
$5,232.57
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$12,147.04
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$9,343.88
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$8,970.12
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$9,904.51
|
| Rate for Payer: Cash Price |
$5,390.70
|
| Rate for Payer: Cigna Commercial |
$17,192.74
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$10,457.96
|
| Rate for Payer: Health EOS Commercial |
$16,632.11
|
| Rate for Payer: HFN Commercial |
$17,192.74
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$14,015.82
|
| Rate for Payer: Multiplan Commercial |
$14,950.21
|
| Rate for Payer: NAPHCARE Commercial |
$11,212.66
|
| Rate for Payer: Preferred Network Access Commercial |
$17,192.74
|
| Rate for Payer: Quartz Beloit One Network |
$9,157.00
|
| Rate for Payer: Quartz Commercial |
$12,147.04
|
| Rate for Payer: Quartz Medicare Advantage |
$11,212.66
|
| Rate for Payer: The Alliance Commercial |
$9,343.88
|
| Rate for Payer: WEA Trust Commercial |
$10,278.27
|
| Rate for Payer: WPS Commercial |
$13,841.52
|
|
|
COMPONENT FEM E-RT GSF FLEX CR 00-5750-015-02
|
Facility
|
IP
|
$17,969.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2967663
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$9,157.00 |
| Max. Negotiated Rate |
$17,192.74 |
| Rate for Payer: Aetna Commercial |
$16,818.98
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$16,071.47
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$9,904.51
|
| Rate for Payer: Cash Price |
$5,390.70
|
| Rate for Payer: Cigna Commercial |
$17,192.74
|
| Rate for Payer: Health EOS Commercial |
$16,632.11
|
| Rate for Payer: HFN Commercial |
$17,192.74
|
| Rate for Payer: Multiplan Commercial |
$14,950.21
|
| Rate for Payer: Preferred Network Access Commercial |
$17,192.74
|
| Rate for Payer: Quartz Beloit One Network |
$9,157.00
|
| Rate for Payer: Quartz Commercial |
$11,212.66
|
| Rate for Payer: WEA Trust Commercial |
$10,278.27
|
| Rate for Payer: WPS Commercial |
$13,841.52
|
|
|
COMPONENT FEM F-LT FLEX CR PRECOAT 5950-16-01
|
Facility
|
IP
|
$18,600.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2967664
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$9,478.56 |
| Max. Negotiated Rate |
$17,796.48 |
| Rate for Payer: Aetna Commercial |
$17,409.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$16,635.84
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$10,252.32
|
| Rate for Payer: Cash Price |
$5,580.00
|
| Rate for Payer: Cigna Commercial |
$17,796.48
|
| Rate for Payer: Health EOS Commercial |
$17,216.16
|
| Rate for Payer: HFN Commercial |
$17,796.48
|
| Rate for Payer: Multiplan Commercial |
$15,475.20
|
| Rate for Payer: Preferred Network Access Commercial |
$17,796.48
|
| Rate for Payer: Quartz Beloit One Network |
$9,478.56
|
| Rate for Payer: Quartz Commercial |
$11,606.40
|
| Rate for Payer: WEA Trust Commercial |
$10,639.20
|
| Rate for Payer: WPS Commercial |
$14,327.58
|
|
|
COMPONENT FEM F-LT FLEX CR PRECOAT 5950-16-01
|
Facility
|
OP
|
$18,600.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2967664
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,416.32 |
| Max. Negotiated Rate |
$17,796.48 |
| Rate for Payer: Aetna Commercial |
$17,409.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$16,635.84
|
| Rate for Payer: Aetna Managed Medicare |
$5,416.32
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$12,573.60
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$9,672.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$9,285.12
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$10,252.32
|
| Rate for Payer: Cash Price |
$5,580.00
|
| Rate for Payer: Cigna Commercial |
$17,796.48
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$10,825.20
|
| Rate for Payer: Health EOS Commercial |
$17,216.16
|
| Rate for Payer: HFN Commercial |
$17,796.48
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$14,508.00
|
| Rate for Payer: Multiplan Commercial |
$15,475.20
|
| Rate for Payer: NAPHCARE Commercial |
$11,606.40
|
| Rate for Payer: Preferred Network Access Commercial |
$17,796.48
|
| Rate for Payer: Quartz Beloit One Network |
$9,478.56
|
| Rate for Payer: Quartz Commercial |
$12,573.60
|
| Rate for Payer: Quartz Medicare Advantage |
$11,606.40
|
| Rate for Payer: The Alliance Commercial |
$9,672.00
|
| Rate for Payer: WEA Trust Commercial |
$10,639.20
|
| Rate for Payer: WPS Commercial |
$14,327.58
|
|
|
COMPONENT FEM F-LT GSF CR FLEX PORUS 00-5752-016-01
|
Facility
|
OP
|
$14,935.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5458863
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,349.07 |
| Max. Negotiated Rate |
$14,289.81 |
| Rate for Payer: Aetna Commercial |
$13,979.16
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$13,357.86
|
| Rate for Payer: Aetna Managed Medicare |
$4,349.07
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$10,096.06
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$7,766.20
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$7,455.55
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$8,232.17
|
| Rate for Payer: Cash Price |
$4,480.50
|
| Rate for Payer: Cigna Commercial |
$14,289.81
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$8,692.17
|
| Rate for Payer: Health EOS Commercial |
$13,823.84
|
| Rate for Payer: HFN Commercial |
$14,289.81
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$11,649.30
|
| Rate for Payer: Multiplan Commercial |
$12,425.92
|
| Rate for Payer: NAPHCARE Commercial |
$9,319.44
|
| Rate for Payer: Preferred Network Access Commercial |
$14,289.81
|
| Rate for Payer: Quartz Beloit One Network |
$7,610.88
|
| Rate for Payer: Quartz Commercial |
$10,096.06
|
| Rate for Payer: Quartz Medicare Advantage |
$9,319.44
|
| Rate for Payer: The Alliance Commercial |
$7,766.20
|
| Rate for Payer: WEA Trust Commercial |
$8,542.82
|
| Rate for Payer: WPS Commercial |
$11,504.43
|
|
|
COMPONENT FEM F-LT GSF CR FLEX PORUS 00-5752-016-01
|
Facility
|
IP
|
$14,935.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5458863
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$7,610.88 |
| Max. Negotiated Rate |
$14,289.81 |
| Rate for Payer: Aetna Commercial |
$13,979.16
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$13,357.86
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$8,232.17
|
| Rate for Payer: Cash Price |
$4,480.50
|
| Rate for Payer: Cigna Commercial |
$14,289.81
|
| Rate for Payer: Health EOS Commercial |
$13,823.84
|
| Rate for Payer: HFN Commercial |
$14,289.81
|
| Rate for Payer: Multiplan Commercial |
$12,425.92
|
| Rate for Payer: Preferred Network Access Commercial |
$14,289.81
|
| Rate for Payer: Quartz Beloit One Network |
$7,610.88
|
| Rate for Payer: Quartz Commercial |
$9,319.44
|
| Rate for Payer: WEA Trust Commercial |
$8,542.82
|
| Rate for Payer: WPS Commercial |
$11,504.43
|
|
|
COMPONENT FEM F-MINUS LT FLEX CR 5950-16-05
|
Facility
|
OP
|
$18,600.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2967666
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,416.32 |
| Max. Negotiated Rate |
$17,796.48 |
| Rate for Payer: Aetna Commercial |
$17,409.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$16,635.84
|
| Rate for Payer: Aetna Managed Medicare |
$5,416.32
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$12,573.60
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$9,672.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$9,285.12
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$10,252.32
|
| Rate for Payer: Cash Price |
$5,580.00
|
| Rate for Payer: Cigna Commercial |
$17,796.48
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$10,825.20
|
| Rate for Payer: Health EOS Commercial |
$17,216.16
|
| Rate for Payer: HFN Commercial |
$17,796.48
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$14,508.00
|
| Rate for Payer: Multiplan Commercial |
$15,475.20
|
| Rate for Payer: NAPHCARE Commercial |
$11,606.40
|
| Rate for Payer: Preferred Network Access Commercial |
$17,796.48
|
| Rate for Payer: Quartz Beloit One Network |
$9,478.56
|
| Rate for Payer: Quartz Commercial |
$12,573.60
|
| Rate for Payer: Quartz Medicare Advantage |
$11,606.40
|
| Rate for Payer: The Alliance Commercial |
$9,672.00
|
| Rate for Payer: WEA Trust Commercial |
$10,639.20
|
| Rate for Payer: WPS Commercial |
$14,327.58
|
|
|
COMPONENT FEM F-MINUS LT FLEX CR 5950-16-05
|
Facility
|
IP
|
$18,600.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2967666
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$9,478.56 |
| Max. Negotiated Rate |
$17,796.48 |
| Rate for Payer: Aetna Commercial |
$17,409.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$16,635.84
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$10,252.32
|
| Rate for Payer: Cash Price |
$5,580.00
|
| Rate for Payer: Cigna Commercial |
$17,796.48
|
| Rate for Payer: Health EOS Commercial |
$17,216.16
|
| Rate for Payer: HFN Commercial |
$17,796.48
|
| Rate for Payer: Multiplan Commercial |
$15,475.20
|
| Rate for Payer: Preferred Network Access Commercial |
$17,796.48
|
| Rate for Payer: Quartz Beloit One Network |
$9,478.56
|
| Rate for Payer: Quartz Commercial |
$11,606.40
|
| Rate for Payer: WEA Trust Commercial |
$10,639.20
|
| Rate for Payer: WPS Commercial |
$14,327.58
|
|
|
COMPONENT FEM F-MINUS LT GSF FLEX CR 00-5750-016-05
|
Facility
|
OP
|
$17,969.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2967667
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,232.57 |
| Max. Negotiated Rate |
$17,192.74 |
| Rate for Payer: Aetna Commercial |
$16,818.98
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$16,071.47
|
| Rate for Payer: Aetna Managed Medicare |
$5,232.57
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$12,147.04
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$9,343.88
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$8,970.12
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$9,904.51
|
| Rate for Payer: Cash Price |
$5,390.70
|
| Rate for Payer: Cigna Commercial |
$17,192.74
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$10,457.96
|
| Rate for Payer: Health EOS Commercial |
$16,632.11
|
| Rate for Payer: HFN Commercial |
$17,192.74
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$14,015.82
|
| Rate for Payer: Multiplan Commercial |
$14,950.21
|
| Rate for Payer: NAPHCARE Commercial |
$11,212.66
|
| Rate for Payer: Preferred Network Access Commercial |
$17,192.74
|
| Rate for Payer: Quartz Beloit One Network |
$9,157.00
|
| Rate for Payer: Quartz Commercial |
$12,147.04
|
| Rate for Payer: Quartz Medicare Advantage |
$11,212.66
|
| Rate for Payer: The Alliance Commercial |
$9,343.88
|
| Rate for Payer: WEA Trust Commercial |
$10,278.27
|
| Rate for Payer: WPS Commercial |
$13,841.52
|
|
|
COMPONENT FEM F-MINUS LT GSF FLEX CR 00-5750-016-05
|
Facility
|
IP
|
$17,969.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2967667
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$9,157.00 |
| Max. Negotiated Rate |
$17,192.74 |
| Rate for Payer: Aetna Commercial |
$16,818.98
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$16,071.47
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$9,904.51
|
| Rate for Payer: Cash Price |
$5,390.70
|
| Rate for Payer: Cigna Commercial |
$17,192.74
|
| Rate for Payer: Health EOS Commercial |
$16,632.11
|
| Rate for Payer: HFN Commercial |
$17,192.74
|
| Rate for Payer: Multiplan Commercial |
$14,950.21
|
| Rate for Payer: Preferred Network Access Commercial |
$17,192.74
|
| Rate for Payer: Quartz Beloit One Network |
$9,157.00
|
| Rate for Payer: Quartz Commercial |
$11,212.66
|
| Rate for Payer: WEA Trust Commercial |
$10,278.27
|
| Rate for Payer: WPS Commercial |
$13,841.52
|
|
|
COMPONENT FEM F-MINUS RT FLEX CR 5950-16-06
|
Facility
|
OP
|
$18,600.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2967668
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,416.32 |
| Max. Negotiated Rate |
$17,796.48 |
| Rate for Payer: Aetna Commercial |
$17,409.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$16,635.84
|
| Rate for Payer: Aetna Managed Medicare |
$5,416.32
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$12,573.60
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$9,672.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$9,285.12
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$10,252.32
|
| Rate for Payer: Cash Price |
$5,580.00
|
| Rate for Payer: Cigna Commercial |
$17,796.48
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$10,825.20
|
| Rate for Payer: Health EOS Commercial |
$17,216.16
|
| Rate for Payer: HFN Commercial |
$17,796.48
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$14,508.00
|
| Rate for Payer: Multiplan Commercial |
$15,475.20
|
| Rate for Payer: NAPHCARE Commercial |
$11,606.40
|
| Rate for Payer: Preferred Network Access Commercial |
$17,796.48
|
| Rate for Payer: Quartz Beloit One Network |
$9,478.56
|
| Rate for Payer: Quartz Commercial |
$12,573.60
|
| Rate for Payer: Quartz Medicare Advantage |
$11,606.40
|
| Rate for Payer: The Alliance Commercial |
$9,672.00
|
| Rate for Payer: WEA Trust Commercial |
$10,639.20
|
| Rate for Payer: WPS Commercial |
$14,327.58
|
|
|
COMPONENT FEM F-MINUS RT FLEX CR 5950-16-06
|
Facility
|
IP
|
$18,600.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2967668
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$9,478.56 |
| Max. Negotiated Rate |
$17,796.48 |
| Rate for Payer: Aetna Commercial |
$17,409.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$16,635.84
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$10,252.32
|
| Rate for Payer: Cash Price |
$5,580.00
|
| Rate for Payer: Cigna Commercial |
$17,796.48
|
| Rate for Payer: Health EOS Commercial |
$17,216.16
|
| Rate for Payer: HFN Commercial |
$17,796.48
|
| Rate for Payer: Multiplan Commercial |
$15,475.20
|
| Rate for Payer: Preferred Network Access Commercial |
$17,796.48
|
| Rate for Payer: Quartz Beloit One Network |
$9,478.56
|
| Rate for Payer: Quartz Commercial |
$11,606.40
|
| Rate for Payer: WEA Trust Commercial |
$10,639.20
|
| Rate for Payer: WPS Commercial |
$14,327.58
|
|
|
COMPONENT FEM F-MINUS RT GSF FLEX CR 00-5750-016-06
|
Facility
|
IP
|
$17,969.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2967669
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$9,157.00 |
| Max. Negotiated Rate |
$17,192.74 |
| Rate for Payer: Aetna Commercial |
$16,818.98
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$16,071.47
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$9,904.51
|
| Rate for Payer: Cash Price |
$5,390.70
|
| Rate for Payer: Cigna Commercial |
$17,192.74
|
| Rate for Payer: Health EOS Commercial |
$16,632.11
|
| Rate for Payer: HFN Commercial |
$17,192.74
|
| Rate for Payer: Multiplan Commercial |
$14,950.21
|
| Rate for Payer: Preferred Network Access Commercial |
$17,192.74
|
| Rate for Payer: Quartz Beloit One Network |
$9,157.00
|
| Rate for Payer: Quartz Commercial |
$11,212.66
|
| Rate for Payer: WEA Trust Commercial |
$10,278.27
|
| Rate for Payer: WPS Commercial |
$13,841.52
|
|
