|
.018 Platinum Plus 300cm
|
Facility
OP
|
$290.00
|
|
|
Service Code
|
HCPCS C1769
|
| Hospital Charge Code |
1158964
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$81.20 |
| Max. Negotiated Rate |
$266.80 |
| Rate for Payer: Aetna Commercial |
$261.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$249.40
|
| Rate for Payer: Aetna Managed Medicare |
$81.20
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$188.50
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$145.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$139.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$153.70
|
| Rate for Payer: Cash Price |
$87.00
|
| Rate for Payer: Cigna Commercial |
$266.80
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$162.28
|
| Rate for Payer: Health EOS Commercial |
$258.10
|
| Rate for Payer: HFN Commercial |
$266.80
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$217.50
|
| Rate for Payer: Multiplan Commercial |
$232.00
|
| Rate for Payer: NAPHCARE Commercial |
$174.00
|
| Rate for Payer: Preferred Network Access Commercial |
$266.80
|
| Rate for Payer: Quartz Beloit One Network |
$142.10
|
| Rate for Payer: Quartz Commercial |
$188.50
|
| Rate for Payer: Quartz Medicare Advantage |
$174.00
|
| Rate for Payer: WEA Trust Commercial |
$159.50
|
| Rate for Payer: WPS Commercial |
$214.80
|
|
|
.018 Platinum Plus 300cm
|
Facility
IP
|
$290.00
|
|
|
Service Code
|
HCPCS C1769
|
| Hospital Charge Code |
1158964
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$142.10 |
| Max. Negotiated Rate |
$266.80 |
| Rate for Payer: Aetna Commercial |
$261.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$153.70
|
| Rate for Payer: Cash Price |
$87.00
|
| Rate for Payer: Cigna Commercial |
$266.80
|
| Rate for Payer: Health EOS Commercial |
$258.10
|
| Rate for Payer: HFN Commercial |
$266.80
|
| Rate for Payer: Multiplan Commercial |
$232.00
|
| Rate for Payer: NAPHCARE Commercial |
$174.00
|
| Rate for Payer: Preferred Network Access Commercial |
$266.80
|
| Rate for Payer: Quartz Beloit One Network |
$142.10
|
| Rate for Payer: Quartz Commercial |
$174.00
|
| Rate for Payer: WEA Trust Commercial |
$159.50
|
| Rate for Payer: WPS Commercial |
$214.80
|
|
|
.018 Platinum Plus 300cm
|
Professional
|
$290.00
|
|
|
Service Code
|
HCPCS C1769
|
| Hospital Charge Code |
1158964
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$127.60 |
| Max. Negotiated Rate |
$275.50 |
| Rate for Payer: Aetna Commercial |
$275.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$249.40
|
| Rate for Payer: Cash Price |
$87.00
|
| Rate for Payer: Cigna Commercial |
$275.50
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$145.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$174.00
|
| Rate for Payer: Health EOS Commercial |
$263.90
|
| Rate for Payer: Multiplan Commercial |
$232.00
|
| Rate for Payer: Preferred Network Access Commercial |
$275.50
|
| Rate for Payer: Quartz Beloit One Network |
$127.60
|
| Rate for Payer: Quartz Commercial |
$165.30
|
| Rate for Payer: The Alliance Commercial |
$145.00
|
| Rate for Payer: WEA Trust Commercial |
$159.50
|
| Rate for Payer: WPS Commercial |
$214.80
|
|
|
.018 STEELCORE WIRE-300CM
|
Facility
OP
|
$1,486.00
|
|
|
Service Code
|
HCPCS C1769
|
| Hospital Charge Code |
5282608
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$416.08 |
| Max. Negotiated Rate |
$1,367.12 |
| Rate for Payer: Aetna Commercial |
$1,337.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,277.96
|
| Rate for Payer: Aetna Managed Medicare |
$416.08
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$965.90
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$743.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$713.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$787.58
|
| Rate for Payer: Cash Price |
$445.80
|
| Rate for Payer: Cigna Commercial |
$1,367.12
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$831.57
|
| Rate for Payer: Health EOS Commercial |
$1,322.54
|
| Rate for Payer: HFN Commercial |
$1,367.12
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,114.50
|
| Rate for Payer: Multiplan Commercial |
$1,188.80
|
| Rate for Payer: NAPHCARE Commercial |
$891.60
|
| Rate for Payer: Preferred Network Access Commercial |
$1,367.12
|
| Rate for Payer: Quartz Beloit One Network |
$728.14
|
| Rate for Payer: Quartz Commercial |
$965.90
|
| Rate for Payer: Quartz Medicare Advantage |
$891.60
|
| Rate for Payer: WEA Trust Commercial |
$817.30
|
| Rate for Payer: WPS Commercial |
$1,100.68
|
|
|
.018 STEELCORE WIRE-300CM
|
Facility
IP
|
$1,486.00
|
|
|
Service Code
|
HCPCS C1769
|
| Hospital Charge Code |
5282608
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$728.14 |
| Max. Negotiated Rate |
$1,367.12 |
| Rate for Payer: Aetna Commercial |
$1,337.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$787.58
|
| Rate for Payer: Cash Price |
$445.80
|
| Rate for Payer: Cigna Commercial |
$1,367.12
|
| Rate for Payer: Health EOS Commercial |
$1,322.54
|
| Rate for Payer: HFN Commercial |
$1,367.12
|
| Rate for Payer: Multiplan Commercial |
$1,188.80
|
| Rate for Payer: NAPHCARE Commercial |
$891.60
|
| Rate for Payer: Preferred Network Access Commercial |
$1,367.12
|
| Rate for Payer: Quartz Beloit One Network |
$728.14
|
| Rate for Payer: Quartz Commercial |
$891.60
|
| Rate for Payer: WEA Trust Commercial |
$817.30
|
| Rate for Payer: WPS Commercial |
$1,100.68
|
|
|
.018 Trail Blazer
|
Facility
OP
|
$2,522.00
|
|
|
Service Code
|
HCPCS C1887
|
| Hospital Charge Code |
5313993
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$706.16 |
| Max. Negotiated Rate |
$2,320.24 |
| Rate for Payer: Aetna Commercial |
$2,269.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,168.92
|
| Rate for Payer: Aetna Managed Medicare |
$706.16
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,639.30
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,261.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,210.56
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,336.66
|
| Rate for Payer: Cash Price |
$756.60
|
| Rate for Payer: Cigna Commercial |
$2,320.24
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,411.31
|
| Rate for Payer: Health EOS Commercial |
$2,244.58
|
| Rate for Payer: HFN Commercial |
$2,320.24
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,891.50
|
| Rate for Payer: Multiplan Commercial |
$2,017.60
|
| Rate for Payer: NAPHCARE Commercial |
$1,513.20
|
| Rate for Payer: Preferred Network Access Commercial |
$2,320.24
|
| Rate for Payer: Quartz Beloit One Network |
$1,235.78
|
| Rate for Payer: Quartz Commercial |
$1,639.30
|
| Rate for Payer: Quartz Medicare Advantage |
$1,513.20
|
| Rate for Payer: WEA Trust Commercial |
$1,387.10
|
| Rate for Payer: WPS Commercial |
$1,868.05
|
|
|
.018 Trail Blazer
|
Facility
IP
|
$2,522.00
|
|
|
Service Code
|
HCPCS C1887
|
| Hospital Charge Code |
5313993
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,235.78 |
| Max. Negotiated Rate |
$2,320.24 |
| Rate for Payer: Aetna Commercial |
$2,269.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,336.66
|
| Rate for Payer: Cash Price |
$756.60
|
| Rate for Payer: Cigna Commercial |
$2,320.24
|
| Rate for Payer: Health EOS Commercial |
$2,244.58
|
| Rate for Payer: HFN Commercial |
$2,320.24
|
| Rate for Payer: Multiplan Commercial |
$2,017.60
|
| Rate for Payer: NAPHCARE Commercial |
$1,513.20
|
| Rate for Payer: Preferred Network Access Commercial |
$2,320.24
|
| Rate for Payer: Quartz Beloit One Network |
$1,235.78
|
| Rate for Payer: Quartz Commercial |
$1,513.20
|
| Rate for Payer: WEA Trust Commercial |
$1,387.10
|
| Rate for Payer: WPS Commercial |
$1,868.05
|
|
|
.018 Victory 18 Wire
|
Facility
IP
|
$2,303.00
|
|
|
Service Code
|
HCPCS C1769
|
| Hospital Charge Code |
4606632
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,128.47 |
| Max. Negotiated Rate |
$2,118.76 |
| Rate for Payer: Aetna Commercial |
$2,072.70
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,220.59
|
| Rate for Payer: Cash Price |
$690.90
|
| Rate for Payer: Cigna Commercial |
$2,118.76
|
| Rate for Payer: Health EOS Commercial |
$2,049.67
|
| Rate for Payer: HFN Commercial |
$2,118.76
|
| Rate for Payer: Multiplan Commercial |
$1,842.40
|
| Rate for Payer: NAPHCARE Commercial |
$1,381.80
|
| Rate for Payer: Preferred Network Access Commercial |
$2,118.76
|
| Rate for Payer: Quartz Beloit One Network |
$1,128.47
|
| Rate for Payer: Quartz Commercial |
$1,381.80
|
| Rate for Payer: WEA Trust Commercial |
$1,266.65
|
| Rate for Payer: WPS Commercial |
$1,705.83
|
|
|
.018 Victory 18 Wire
|
Facility
OP
|
$2,303.00
|
|
|
Service Code
|
HCPCS C1769
|
| Hospital Charge Code |
4606632
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$644.84 |
| Max. Negotiated Rate |
$2,118.76 |
| Rate for Payer: Aetna Commercial |
$2,072.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,980.58
|
| Rate for Payer: Aetna Managed Medicare |
$644.84
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,496.95
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,151.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,105.44
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,220.59
|
| Rate for Payer: Cash Price |
$690.90
|
| Rate for Payer: Cigna Commercial |
$2,118.76
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,288.76
|
| Rate for Payer: Health EOS Commercial |
$2,049.67
|
| Rate for Payer: HFN Commercial |
$2,118.76
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,727.25
|
| Rate for Payer: Multiplan Commercial |
$1,842.40
|
| Rate for Payer: NAPHCARE Commercial |
$1,381.80
|
| Rate for Payer: Preferred Network Access Commercial |
$2,118.76
|
| Rate for Payer: Quartz Beloit One Network |
$1,128.47
|
| Rate for Payer: Quartz Commercial |
$1,496.95
|
| Rate for Payer: Quartz Medicare Advantage |
$1,381.80
|
| Rate for Payer: WEA Trust Commercial |
$1,266.65
|
| Rate for Payer: WPS Commercial |
$1,705.83
|
|
|
.018 Zip Angled 180cm
|
Facility
OP
|
$290.00
|
|
|
Service Code
|
HCPCS C1769
|
| Hospital Charge Code |
1158960
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$81.20 |
| Max. Negotiated Rate |
$266.80 |
| Rate for Payer: Aetna Commercial |
$261.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$249.40
|
| Rate for Payer: Aetna Managed Medicare |
$81.20
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$188.50
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$145.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$139.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$153.70
|
| Rate for Payer: Cash Price |
$87.00
|
| Rate for Payer: Cigna Commercial |
$266.80
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$162.28
|
| Rate for Payer: Health EOS Commercial |
$258.10
|
| Rate for Payer: HFN Commercial |
$266.80
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$217.50
|
| Rate for Payer: Multiplan Commercial |
$232.00
|
| Rate for Payer: NAPHCARE Commercial |
$174.00
|
| Rate for Payer: Preferred Network Access Commercial |
$266.80
|
| Rate for Payer: Quartz Beloit One Network |
$142.10
|
| Rate for Payer: Quartz Commercial |
$188.50
|
| Rate for Payer: Quartz Medicare Advantage |
$174.00
|
| Rate for Payer: WEA Trust Commercial |
$159.50
|
| Rate for Payer: WPS Commercial |
$214.80
|
|
|
.018 Zip Angled 180cm
|
Facility
IP
|
$290.00
|
|
|
Service Code
|
HCPCS C1769
|
| Hospital Charge Code |
1158960
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$142.10 |
| Max. Negotiated Rate |
$266.80 |
| Rate for Payer: Aetna Commercial |
$261.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$153.70
|
| Rate for Payer: Cash Price |
$87.00
|
| Rate for Payer: Cigna Commercial |
$266.80
|
| Rate for Payer: Health EOS Commercial |
$258.10
|
| Rate for Payer: HFN Commercial |
$266.80
|
| Rate for Payer: Multiplan Commercial |
$232.00
|
| Rate for Payer: NAPHCARE Commercial |
$174.00
|
| Rate for Payer: Preferred Network Access Commercial |
$266.80
|
| Rate for Payer: Quartz Beloit One Network |
$142.10
|
| Rate for Payer: Quartz Commercial |
$174.00
|
| Rate for Payer: WEA Trust Commercial |
$159.50
|
| Rate for Payer: WPS Commercial |
$214.80
|
|
|
.018 Zip Angled 180cm
|
Professional
|
$290.00
|
|
|
Service Code
|
HCPCS C1769
|
| Hospital Charge Code |
1158960
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$127.60 |
| Max. Negotiated Rate |
$275.50 |
| Rate for Payer: Aetna Commercial |
$275.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$249.40
|
| Rate for Payer: Cash Price |
$87.00
|
| Rate for Payer: Cigna Commercial |
$275.50
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$145.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$174.00
|
| Rate for Payer: Health EOS Commercial |
$263.90
|
| Rate for Payer: Multiplan Commercial |
$232.00
|
| Rate for Payer: Preferred Network Access Commercial |
$275.50
|
| Rate for Payer: Quartz Beloit One Network |
$127.60
|
| Rate for Payer: Quartz Commercial |
$165.30
|
| Rate for Payer: The Alliance Commercial |
$145.00
|
| Rate for Payer: WEA Trust Commercial |
$159.50
|
| Rate for Payer: WPS Commercial |
$214.80
|
|
|
.035 3mm J
|
Facility
OP
|
$290.00
|
|
|
Service Code
|
HCPCS C1769
|
| Hospital Charge Code |
1158968
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$81.20 |
| Max. Negotiated Rate |
$266.80 |
| Rate for Payer: Aetna Commercial |
$261.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$249.40
|
| Rate for Payer: Aetna Managed Medicare |
$81.20
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$188.50
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$145.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$139.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$153.70
|
| Rate for Payer: Cash Price |
$87.00
|
| Rate for Payer: Cigna Commercial |
$266.80
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$162.28
|
| Rate for Payer: Health EOS Commercial |
$258.10
|
| Rate for Payer: HFN Commercial |
$266.80
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$217.50
|
| Rate for Payer: Multiplan Commercial |
$232.00
|
| Rate for Payer: NAPHCARE Commercial |
$174.00
|
| Rate for Payer: Preferred Network Access Commercial |
$266.80
|
| Rate for Payer: Quartz Beloit One Network |
$142.10
|
| Rate for Payer: Quartz Commercial |
$188.50
|
| Rate for Payer: Quartz Medicare Advantage |
$174.00
|
| Rate for Payer: WEA Trust Commercial |
$159.50
|
| Rate for Payer: WPS Commercial |
$214.80
|
|
|
.035 3mm J
|
Professional
|
$290.00
|
|
|
Service Code
|
HCPCS C1769
|
| Hospital Charge Code |
1158968
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$127.60 |
| Max. Negotiated Rate |
$275.50 |
| Rate for Payer: Aetna Commercial |
$275.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$249.40
|
| Rate for Payer: Cash Price |
$87.00
|
| Rate for Payer: Cigna Commercial |
$275.50
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$145.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$174.00
|
| Rate for Payer: Health EOS Commercial |
$263.90
|
| Rate for Payer: Multiplan Commercial |
$232.00
|
| Rate for Payer: Preferred Network Access Commercial |
$275.50
|
| Rate for Payer: Quartz Beloit One Network |
$127.60
|
| Rate for Payer: Quartz Commercial |
$165.30
|
| Rate for Payer: The Alliance Commercial |
$145.00
|
| Rate for Payer: WEA Trust Commercial |
$159.50
|
| Rate for Payer: WPS Commercial |
$214.80
|
|
|
.035 3mm J
|
Facility
IP
|
$290.00
|
|
|
Service Code
|
HCPCS C1769
|
| Hospital Charge Code |
1158968
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$142.10 |
| Max. Negotiated Rate |
$266.80 |
| Rate for Payer: Aetna Commercial |
$261.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$153.70
|
| Rate for Payer: Cash Price |
$87.00
|
| Rate for Payer: Cigna Commercial |
$266.80
|
| Rate for Payer: Health EOS Commercial |
$258.10
|
| Rate for Payer: HFN Commercial |
$266.80
|
| Rate for Payer: Multiplan Commercial |
$232.00
|
| Rate for Payer: NAPHCARE Commercial |
$174.00
|
| Rate for Payer: Preferred Network Access Commercial |
$266.80
|
| Rate for Payer: Quartz Beloit One Network |
$142.10
|
| Rate for Payer: Quartz Commercial |
$174.00
|
| Rate for Payer: WEA Trust Commercial |
$159.50
|
| Rate for Payer: WPS Commercial |
$214.80
|
|
|
.035 Amplatz 180cm
|
Facility
OP
|
$290.00
|
|
|
Service Code
|
HCPCS C1769
|
| Hospital Charge Code |
1158982
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$81.20 |
| Max. Negotiated Rate |
$266.80 |
| Rate for Payer: Aetna Commercial |
$261.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$249.40
|
| Rate for Payer: Aetna Managed Medicare |
$81.20
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$188.50
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$145.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$139.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$153.70
|
| Rate for Payer: Cash Price |
$87.00
|
| Rate for Payer: Cigna Commercial |
$266.80
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$162.28
|
| Rate for Payer: Health EOS Commercial |
$258.10
|
| Rate for Payer: HFN Commercial |
$266.80
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$217.50
|
| Rate for Payer: Multiplan Commercial |
$232.00
|
| Rate for Payer: NAPHCARE Commercial |
$174.00
|
| Rate for Payer: Preferred Network Access Commercial |
$266.80
|
| Rate for Payer: Quartz Beloit One Network |
$142.10
|
| Rate for Payer: Quartz Commercial |
$188.50
|
| Rate for Payer: Quartz Medicare Advantage |
$174.00
|
| Rate for Payer: WEA Trust Commercial |
$159.50
|
| Rate for Payer: WPS Commercial |
$214.80
|
|
|
.035 Amplatz 180cm
|
Professional
|
$290.00
|
|
|
Service Code
|
HCPCS C1769
|
| Hospital Charge Code |
1158982
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$127.60 |
| Max. Negotiated Rate |
$275.50 |
| Rate for Payer: Aetna Commercial |
$275.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$249.40
|
| Rate for Payer: Cash Price |
$87.00
|
| Rate for Payer: Cigna Commercial |
$275.50
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$145.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$174.00
|
| Rate for Payer: Health EOS Commercial |
$263.90
|
| Rate for Payer: Multiplan Commercial |
$232.00
|
| Rate for Payer: Preferred Network Access Commercial |
$275.50
|
| Rate for Payer: Quartz Beloit One Network |
$127.60
|
| Rate for Payer: Quartz Commercial |
$165.30
|
| Rate for Payer: The Alliance Commercial |
$145.00
|
| Rate for Payer: WEA Trust Commercial |
$159.50
|
| Rate for Payer: WPS Commercial |
$214.80
|
|
|
.035 Amplatz 180cm
|
Facility
IP
|
$290.00
|
|
|
Service Code
|
HCPCS C1769
|
| Hospital Charge Code |
1158982
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$142.10 |
| Max. Negotiated Rate |
$266.80 |
| Rate for Payer: Aetna Commercial |
$261.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$153.70
|
| Rate for Payer: Cash Price |
$87.00
|
| Rate for Payer: Cigna Commercial |
$266.80
|
| Rate for Payer: Health EOS Commercial |
$258.10
|
| Rate for Payer: HFN Commercial |
$266.80
|
| Rate for Payer: Multiplan Commercial |
$232.00
|
| Rate for Payer: NAPHCARE Commercial |
$174.00
|
| Rate for Payer: Preferred Network Access Commercial |
$266.80
|
| Rate for Payer: Quartz Beloit One Network |
$142.10
|
| Rate for Payer: Quartz Commercial |
$174.00
|
| Rate for Payer: WEA Trust Commercial |
$159.50
|
| Rate for Payer: WPS Commercial |
$214.80
|
|
|
.035 Amplatz 300cm
|
Facility
IP
|
$290.00
|
|
|
Service Code
|
HCPCS C1769
|
| Hospital Charge Code |
1158984
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$142.10 |
| Max. Negotiated Rate |
$266.80 |
| Rate for Payer: Aetna Commercial |
$261.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$153.70
|
| Rate for Payer: Cash Price |
$87.00
|
| Rate for Payer: Cigna Commercial |
$266.80
|
| Rate for Payer: Health EOS Commercial |
$258.10
|
| Rate for Payer: HFN Commercial |
$266.80
|
| Rate for Payer: Multiplan Commercial |
$232.00
|
| Rate for Payer: NAPHCARE Commercial |
$174.00
|
| Rate for Payer: Preferred Network Access Commercial |
$266.80
|
| Rate for Payer: Quartz Beloit One Network |
$142.10
|
| Rate for Payer: Quartz Commercial |
$174.00
|
| Rate for Payer: WEA Trust Commercial |
$159.50
|
| Rate for Payer: WPS Commercial |
$214.80
|
|
|
.035 Amplatz 300cm
|
Facility
OP
|
$290.00
|
|
|
Service Code
|
HCPCS C1769
|
| Hospital Charge Code |
1158984
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$81.20 |
| Max. Negotiated Rate |
$266.80 |
| Rate for Payer: Aetna Commercial |
$261.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$249.40
|
| Rate for Payer: Aetna Managed Medicare |
$81.20
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$188.50
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$145.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$139.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$153.70
|
| Rate for Payer: Cash Price |
$87.00
|
| Rate for Payer: Cigna Commercial |
$266.80
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$162.28
|
| Rate for Payer: Health EOS Commercial |
$258.10
|
| Rate for Payer: HFN Commercial |
$266.80
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$217.50
|
| Rate for Payer: Multiplan Commercial |
$232.00
|
| Rate for Payer: NAPHCARE Commercial |
$174.00
|
| Rate for Payer: Preferred Network Access Commercial |
$266.80
|
| Rate for Payer: Quartz Beloit One Network |
$142.10
|
| Rate for Payer: Quartz Commercial |
$188.50
|
| Rate for Payer: Quartz Medicare Advantage |
$174.00
|
| Rate for Payer: WEA Trust Commercial |
$159.50
|
| Rate for Payer: WPS Commercial |
$214.80
|
|
|
.035 Amplatz 300cm
|
Professional
|
$290.00
|
|
|
Service Code
|
HCPCS C1769
|
| Hospital Charge Code |
1158984
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$127.60 |
| Max. Negotiated Rate |
$275.50 |
| Rate for Payer: Aetna Commercial |
$275.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$249.40
|
| Rate for Payer: Cash Price |
$87.00
|
| Rate for Payer: Cigna Commercial |
$275.50
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$145.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$174.00
|
| Rate for Payer: Health EOS Commercial |
$263.90
|
| Rate for Payer: Multiplan Commercial |
$232.00
|
| Rate for Payer: Preferred Network Access Commercial |
$275.50
|
| Rate for Payer: Quartz Beloit One Network |
$127.60
|
| Rate for Payer: Quartz Commercial |
$165.30
|
| Rate for Payer: The Alliance Commercial |
$145.00
|
| Rate for Payer: WEA Trust Commercial |
$159.50
|
| Rate for Payer: WPS Commercial |
$214.80
|
|
|
.035 Lunderquist 180cm
|
Facility
OP
|
$290.00
|
|
|
Service Code
|
HCPCS C1769
|
| Hospital Charge Code |
1158986
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$81.20 |
| Max. Negotiated Rate |
$266.80 |
| Rate for Payer: Aetna Commercial |
$261.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$249.40
|
| Rate for Payer: Aetna Managed Medicare |
$81.20
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$188.50
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$145.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$139.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$153.70
|
| Rate for Payer: Cash Price |
$87.00
|
| Rate for Payer: Cigna Commercial |
$266.80
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$162.28
|
| Rate for Payer: Health EOS Commercial |
$258.10
|
| Rate for Payer: HFN Commercial |
$266.80
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$217.50
|
| Rate for Payer: Multiplan Commercial |
$232.00
|
| Rate for Payer: NAPHCARE Commercial |
$174.00
|
| Rate for Payer: Preferred Network Access Commercial |
$266.80
|
| Rate for Payer: Quartz Beloit One Network |
$142.10
|
| Rate for Payer: Quartz Commercial |
$188.50
|
| Rate for Payer: Quartz Medicare Advantage |
$174.00
|
| Rate for Payer: WEA Trust Commercial |
$159.50
|
| Rate for Payer: WPS Commercial |
$214.80
|
|
|
.035 Lunderquist 180cm
|
Professional
|
$290.00
|
|
|
Service Code
|
HCPCS C1769
|
| Hospital Charge Code |
1158986
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$127.60 |
| Max. Negotiated Rate |
$275.50 |
| Rate for Payer: Aetna Commercial |
$275.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$249.40
|
| Rate for Payer: Cash Price |
$87.00
|
| Rate for Payer: Cigna Commercial |
$275.50
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$145.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$174.00
|
| Rate for Payer: Health EOS Commercial |
$263.90
|
| Rate for Payer: Multiplan Commercial |
$232.00
|
| Rate for Payer: Preferred Network Access Commercial |
$275.50
|
| Rate for Payer: Quartz Beloit One Network |
$127.60
|
| Rate for Payer: Quartz Commercial |
$165.30
|
| Rate for Payer: The Alliance Commercial |
$145.00
|
| Rate for Payer: WEA Trust Commercial |
$159.50
|
| Rate for Payer: WPS Commercial |
$214.80
|
|
|
.035 Lunderquist 180cm
|
Facility
IP
|
$290.00
|
|
|
Service Code
|
HCPCS C1769
|
| Hospital Charge Code |
1158986
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$142.10 |
| Max. Negotiated Rate |
$266.80 |
| Rate for Payer: Aetna Commercial |
$261.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$153.70
|
| Rate for Payer: Cash Price |
$87.00
|
| Rate for Payer: Cigna Commercial |
$266.80
|
| Rate for Payer: Health EOS Commercial |
$258.10
|
| Rate for Payer: HFN Commercial |
$266.80
|
| Rate for Payer: Multiplan Commercial |
$232.00
|
| Rate for Payer: NAPHCARE Commercial |
$174.00
|
| Rate for Payer: Preferred Network Access Commercial |
$266.80
|
| Rate for Payer: Quartz Beloit One Network |
$142.10
|
| Rate for Payer: Quartz Commercial |
$174.00
|
| Rate for Payer: WEA Trust Commercial |
$159.50
|
| Rate for Payer: WPS Commercial |
$214.80
|
|
|
.035 Lunderquist 300cm
|
Facility
OP
|
$290.00
|
|
|
Service Code
|
HCPCS C1769
|
| Hospital Charge Code |
1158988
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$81.20 |
| Max. Negotiated Rate |
$266.80 |
| Rate for Payer: Aetna Commercial |
$261.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$249.40
|
| Rate for Payer: Aetna Managed Medicare |
$81.20
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$188.50
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$145.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$139.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$153.70
|
| Rate for Payer: Cash Price |
$87.00
|
| Rate for Payer: Cigna Commercial |
$266.80
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$162.28
|
| Rate for Payer: Health EOS Commercial |
$258.10
|
| Rate for Payer: HFN Commercial |
$266.80
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$217.50
|
| Rate for Payer: Multiplan Commercial |
$232.00
|
| Rate for Payer: NAPHCARE Commercial |
$174.00
|
| Rate for Payer: Preferred Network Access Commercial |
$266.80
|
| Rate for Payer: Quartz Beloit One Network |
$142.10
|
| Rate for Payer: Quartz Commercial |
$188.50
|
| Rate for Payer: Quartz Medicare Advantage |
$174.00
|
| Rate for Payer: WEA Trust Commercial |
$159.50
|
| Rate for Payer: WPS Commercial |
$214.80
|
|
