|
.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
|
|
|
.035 Lunderquist 300cm
|
Professional
|
$290.00
|
|
|
Service Code
|
HCPCS C1769
|
| Hospital Charge Code |
1158988
|
|
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 Wire-260CM
|
Facility
IP
|
$1,550.00
|
|
|
Service Code
|
HCPCS C1769
|
| Hospital Charge Code |
4606630
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$759.50 |
| Max. Negotiated Rate |
$1,426.00 |
| Rate for Payer: Aetna Commercial |
$1,395.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$821.50
|
| Rate for Payer: Cash Price |
$465.00
|
| Rate for Payer: Cigna Commercial |
$1,426.00
|
| Rate for Payer: Health EOS Commercial |
$1,379.50
|
| Rate for Payer: HFN Commercial |
$1,426.00
|
| Rate for Payer: Multiplan Commercial |
$1,240.00
|
| Rate for Payer: NAPHCARE Commercial |
$930.00
|
| Rate for Payer: Preferred Network Access Commercial |
$1,426.00
|
| Rate for Payer: Quartz Beloit One Network |
$759.50
|
| Rate for Payer: Quartz Commercial |
$930.00
|
| Rate for Payer: WEA Trust Commercial |
$852.50
|
| Rate for Payer: WPS Commercial |
$1,148.08
|
|
|
.035 Lunderquist Wire-260CM
|
Facility
OP
|
$1,550.00
|
|
|
Service Code
|
HCPCS C1769
|
| Hospital Charge Code |
4606630
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$434.00 |
| Max. Negotiated Rate |
$1,426.00 |
| Rate for Payer: Aetna Commercial |
$1,395.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,333.00
|
| Rate for Payer: Aetna Managed Medicare |
$434.00
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,007.50
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$775.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$744.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$821.50
|
| Rate for Payer: Cash Price |
$465.00
|
| Rate for Payer: Cigna Commercial |
$1,426.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$867.38
|
| Rate for Payer: Health EOS Commercial |
$1,379.50
|
| Rate for Payer: HFN Commercial |
$1,426.00
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,162.50
|
| Rate for Payer: Multiplan Commercial |
$1,240.00
|
| Rate for Payer: NAPHCARE Commercial |
$930.00
|
| Rate for Payer: Preferred Network Access Commercial |
$1,426.00
|
| Rate for Payer: Quartz Beloit One Network |
$759.50
|
| Rate for Payer: Quartz Commercial |
$1,007.50
|
| Rate for Payer: Quartz Medicare Advantage |
$930.00
|
| Rate for Payer: WEA Trust Commercial |
$852.50
|
| Rate for Payer: WPS Commercial |
$1,148.08
|
|
|
.035 Storq 180cm
|
Facility
IP
|
$290.00
|
|
|
Service Code
|
HCPCS C1769
|
| Hospital Charge Code |
1158970
|
|
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 Storq 180cm
|
Professional
|
$290.00
|
|
|
Service Code
|
HCPCS C1769
|
| Hospital Charge Code |
1158970
|
|
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 Storq 180cm
|
Facility
OP
|
$290.00
|
|
|
Service Code
|
HCPCS C1769
|
| Hospital Charge Code |
1158970
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$81.20 |
| Max. Negotiated Rate |
$266.80 |
| Rate for Payer: Dean Health DHI/DHP/ASO |
$162.28
|
| 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: 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 Storq 300cm
|
Facility
IP
|
$290.00
|
|
|
Service Code
|
HCPCS C1769
|
| Hospital Charge Code |
1158972
|
|
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 Storq 300cm
|
Professional
|
$290.00
|
|
|
Service Code
|
HCPCS C1769
|
| Hospital Charge Code |
1158972
|
|
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 Storq 300cm
|
Facility
OP
|
$290.00
|
|
|
Service Code
|
HCPCS C1769
|
| Hospital Charge Code |
1158972
|
|
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 ST WIRE -150CM
|
Facility
OP
|
$170.00
|
|
|
Service Code
|
HCPCS C1769
|
| Hospital Charge Code |
5282607
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$47.60 |
| Max. Negotiated Rate |
$156.40 |
| Rate for Payer: Aetna Commercial |
$153.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$146.20
|
| Rate for Payer: Aetna Managed Medicare |
$47.60
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$110.50
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$85.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$81.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$90.10
|
| Rate for Payer: Cash Price |
$51.00
|
| Rate for Payer: Cigna Commercial |
$156.40
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$95.13
|
| Rate for Payer: Health EOS Commercial |
$151.30
|
| Rate for Payer: HFN Commercial |
$156.40
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$127.50
|
| Rate for Payer: Multiplan Commercial |
$136.00
|
| Rate for Payer: NAPHCARE Commercial |
$102.00
|
| Rate for Payer: Preferred Network Access Commercial |
$156.40
|
| Rate for Payer: Quartz Beloit One Network |
$83.30
|
| Rate for Payer: Quartz Commercial |
$110.50
|
| Rate for Payer: Quartz Medicare Advantage |
$102.00
|
| Rate for Payer: WEA Trust Commercial |
$93.50
|
| Rate for Payer: WPS Commercial |
$125.92
|
|
|
.035 ST WIRE -150CM
|
Facility
IP
|
$170.00
|
|
|
Service Code
|
HCPCS C1769
|
| Hospital Charge Code |
5282607
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$83.30 |
| Max. Negotiated Rate |
$156.40 |
| Rate for Payer: Aetna Commercial |
$153.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$90.10
|
| Rate for Payer: Cash Price |
$51.00
|
| Rate for Payer: Cigna Commercial |
$156.40
|
| Rate for Payer: Health EOS Commercial |
$151.30
|
| Rate for Payer: HFN Commercial |
$156.40
|
| Rate for Payer: Multiplan Commercial |
$136.00
|
| Rate for Payer: NAPHCARE Commercial |
$102.00
|
| Rate for Payer: Preferred Network Access Commercial |
$156.40
|
| Rate for Payer: Quartz Beloit One Network |
$83.30
|
| Rate for Payer: Quartz Commercial |
$102.00
|
| Rate for Payer: WEA Trust Commercial |
$93.50
|
| Rate for Payer: WPS Commercial |
$125.92
|
|
|
.035 ST WIRE 260-CM
|
Facility
OP
|
$196.00
|
|
|
Service Code
|
HCPCS C1769
|
| Hospital Charge Code |
5282606
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$54.88 |
| Max. Negotiated Rate |
$180.32 |
| Rate for Payer: Aetna Commercial |
$176.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$168.56
|
| Rate for Payer: Aetna Managed Medicare |
$54.88
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$127.40
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$98.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$94.08
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$103.88
|
| Rate for Payer: Cash Price |
$58.80
|
| Rate for Payer: Cigna Commercial |
$180.32
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$109.68
|
| Rate for Payer: Health EOS Commercial |
$174.44
|
| Rate for Payer: HFN Commercial |
$180.32
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$147.00
|
| Rate for Payer: Multiplan Commercial |
$156.80
|
| Rate for Payer: NAPHCARE Commercial |
$117.60
|
| Rate for Payer: Preferred Network Access Commercial |
$180.32
|
| Rate for Payer: Quartz Beloit One Network |
$96.04
|
| Rate for Payer: Quartz Commercial |
$127.40
|
| Rate for Payer: Quartz Medicare Advantage |
$117.60
|
| Rate for Payer: WEA Trust Commercial |
$107.80
|
| Rate for Payer: WPS Commercial |
$145.18
|
|
|
.035 ST WIRE 260-CM
|
Facility
IP
|
$196.00
|
|
|
Service Code
|
HCPCS C1769
|
| Hospital Charge Code |
5282606
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$96.04 |
| Max. Negotiated Rate |
$180.32 |
| Rate for Payer: Aetna Commercial |
$176.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$103.88
|
| Rate for Payer: Cash Price |
$58.80
|
| Rate for Payer: Cigna Commercial |
$180.32
|
| Rate for Payer: Health EOS Commercial |
$174.44
|
| Rate for Payer: HFN Commercial |
$180.32
|
| Rate for Payer: Multiplan Commercial |
$156.80
|
| Rate for Payer: NAPHCARE Commercial |
$117.60
|
| Rate for Payer: Preferred Network Access Commercial |
$180.32
|
| Rate for Payer: Quartz Beloit One Network |
$96.04
|
| Rate for Payer: Quartz Commercial |
$117.60
|
| Rate for Payer: WEA Trust Commercial |
$107.80
|
| Rate for Payer: WPS Commercial |
$145.18
|
|
|
.035 Zip Angled 180cm
|
Facility
OP
|
$290.00
|
|
|
Service Code
|
HCPCS C1769
|
| Hospital Charge Code |
1158974
|
|
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 Zip Angled 180cm
|
Facility
IP
|
$290.00
|
|
|
Service Code
|
HCPCS C1769
|
| Hospital Charge Code |
1158974
|
|
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 Zip Angled 180cm
|
Professional
|
$290.00
|
|
|
Service Code
|
HCPCS C1769
|
| Hospital Charge Code |
1158974
|
|
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 Zip Angled 300cm
|
Facility
IP
|
$290.00
|
|
|
Service Code
|
HCPCS C1769
|
| Hospital Charge Code |
1158978
|
|
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 Zip Angled 300cm
|
Facility
OP
|
$290.00
|
|
|
Service Code
|
HCPCS C1769
|
| Hospital Charge Code |
1158978
|
|
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 Zip Angled 300cm
|
Professional
|
$290.00
|
|
|
Service Code
|
HCPCS C1769
|
| Hospital Charge Code |
1158978
|
|
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 Zip Strait 180cm
|
Professional
|
$290.00
|
|
|
Service Code
|
HCPCS C1769
|
| Hospital Charge Code |
1158976
|
|
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 Zip Strait 180cm
|
Facility
OP
|
$290.00
|
|
|
Service Code
|
HCPCS C1769
|
| Hospital Charge Code |
1158976
|
|
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 Zip Strait 180cm
|
Facility
IP
|
$290.00
|
|
|
Service Code
|
HCPCS C1769
|
| Hospital Charge Code |
1158976
|
|
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 Zip Strait 300cm
|
Facility
IP
|
$290.00
|
|
|
Service Code
|
HCPCS C1769
|
| Hospital Charge Code |
1158980
|
|
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 Zip Strait 300cm
|
Professional
|
$290.00
|
|
|
Service Code
|
HCPCS C1769
|
| Hospital Charge Code |
1158980
|
|
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
|
|
