|
INSERT TRIDENT 0 DEG 36MM E 623-00-36E
|
Facility
|
IP
|
$6,332.00
|
|
| Hospital Charge Code |
4595053
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,102.68 |
| Max. Negotiated Rate |
$5,825.44 |
| Rate for Payer: Aetna Commercial |
$5,698.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,445.52
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,355.96
|
| Rate for Payer: Cash Price |
$1,899.60
|
| Rate for Payer: Cigna Commercial |
$5,825.44
|
| Rate for Payer: Health EOS Commercial |
$5,635.48
|
| Rate for Payer: HFN Commercial |
$5,825.44
|
| Rate for Payer: Multiplan Commercial |
$5,065.60
|
| Rate for Payer: NAPHCARE Commercial |
$3,799.20
|
| Rate for Payer: Preferred Network Access Commercial |
$5,825.44
|
| Rate for Payer: Quartz Beloit One Network |
$3,102.68
|
| Rate for Payer: Quartz Commercial |
$3,799.20
|
| Rate for Payer: WEA Trust Commercial |
$3,482.60
|
| Rate for Payer: WPS Commercial |
$4,690.11
|
|
|
INSERT TRIDENT 0 DEG 36MM F 623-00-36F
|
Facility
|
IP
|
$6,096.00
|
|
| Hospital Charge Code |
3297468
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,987.04 |
| Max. Negotiated Rate |
$5,608.32 |
| Rate for Payer: Aetna Commercial |
$5,486.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,242.56
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,230.88
|
| Rate for Payer: Cash Price |
$1,828.80
|
| Rate for Payer: Cigna Commercial |
$5,608.32
|
| Rate for Payer: Health EOS Commercial |
$5,425.44
|
| Rate for Payer: HFN Commercial |
$5,608.32
|
| Rate for Payer: Multiplan Commercial |
$4,876.80
|
| Rate for Payer: NAPHCARE Commercial |
$3,657.60
|
| Rate for Payer: Preferred Network Access Commercial |
$5,608.32
|
| Rate for Payer: Quartz Beloit One Network |
$2,987.04
|
| Rate for Payer: Quartz Commercial |
$3,657.60
|
| Rate for Payer: WEA Trust Commercial |
$3,352.80
|
| Rate for Payer: WPS Commercial |
$4,515.31
|
|
|
INSERT TRIDENT 0 DEG 36MM F 623-00-36F
|
Facility
|
OP
|
$6,096.00
|
|
| Hospital Charge Code |
3297468
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,706.88 |
| Max. Negotiated Rate |
$24,384.00 |
| Rate for Payer: Aetna Commercial |
$5,486.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,242.56
|
| Rate for Payer: Aetna Managed Medicare |
$1,706.88
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,962.40
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,048.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,926.08
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,230.88
|
| Rate for Payer: Cash Price |
$1,828.80
|
| Rate for Payer: Cigna Commercial |
$5,608.32
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,411.32
|
| Rate for Payer: Health EOS Commercial |
$5,425.44
|
| Rate for Payer: HFN Commercial |
$5,608.32
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,572.00
|
| Rate for Payer: Multiplan Commercial |
$4,876.80
|
| Rate for Payer: NAPHCARE Commercial |
$3,657.60
|
| Rate for Payer: Preferred Network Access Commercial |
$5,608.32
|
| Rate for Payer: Quartz Beloit One Network |
$2,987.04
|
| Rate for Payer: Quartz Commercial |
$3,962.40
|
| Rate for Payer: Quartz Medicare Advantage |
$3,657.60
|
| Rate for Payer: The Alliance Commercial |
$24,384.00
|
| Rate for Payer: WEA Trust Commercial |
$3,352.80
|
| Rate for Payer: WPS Commercial |
$4,515.31
|
|
|
INSERT TRIDENT 0 DEG 40MM E 623-00-40E
|
Facility
|
OP
|
$6,096.00
|
|
| Hospital Charge Code |
3949332
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,706.88 |
| Max. Negotiated Rate |
$24,384.00 |
| Rate for Payer: Aetna Commercial |
$5,486.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,242.56
|
| Rate for Payer: Aetna Managed Medicare |
$1,706.88
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,962.40
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,048.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,926.08
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,230.88
|
| Rate for Payer: Cash Price |
$1,828.80
|
| Rate for Payer: Cigna Commercial |
$5,608.32
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,411.32
|
| Rate for Payer: Health EOS Commercial |
$5,425.44
|
| Rate for Payer: HFN Commercial |
$5,608.32
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,572.00
|
| Rate for Payer: Multiplan Commercial |
$4,876.80
|
| Rate for Payer: NAPHCARE Commercial |
$3,657.60
|
| Rate for Payer: Preferred Network Access Commercial |
$5,608.32
|
| Rate for Payer: Quartz Beloit One Network |
$2,987.04
|
| Rate for Payer: Quartz Commercial |
$3,962.40
|
| Rate for Payer: Quartz Medicare Advantage |
$3,657.60
|
| Rate for Payer: The Alliance Commercial |
$24,384.00
|
| Rate for Payer: WEA Trust Commercial |
$3,352.80
|
| Rate for Payer: WPS Commercial |
$4,515.31
|
|
|
INSERT TRIDENT 0 DEG 40MM E 623-00-40E
|
Facility
|
IP
|
$6,096.00
|
|
| Hospital Charge Code |
3949332
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,987.04 |
| Max. Negotiated Rate |
$5,608.32 |
| Rate for Payer: Aetna Commercial |
$5,486.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,242.56
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,230.88
|
| Rate for Payer: Cash Price |
$1,828.80
|
| Rate for Payer: Cigna Commercial |
$5,608.32
|
| Rate for Payer: Health EOS Commercial |
$5,425.44
|
| Rate for Payer: HFN Commercial |
$5,608.32
|
| Rate for Payer: Multiplan Commercial |
$4,876.80
|
| Rate for Payer: NAPHCARE Commercial |
$3,657.60
|
| Rate for Payer: Preferred Network Access Commercial |
$5,608.32
|
| Rate for Payer: Quartz Beloit One Network |
$2,987.04
|
| Rate for Payer: Quartz Commercial |
$3,657.60
|
| Rate for Payer: WEA Trust Commercial |
$3,352.80
|
| Rate for Payer: WPS Commercial |
$4,515.31
|
|
|
INSERT TRIDENT 0 DEG 40MM F 623-00-40F
|
Facility
|
IP
|
$6,096.00
|
|
| Hospital Charge Code |
3779520
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,987.04 |
| Max. Negotiated Rate |
$5,608.32 |
| Rate for Payer: Aetna Commercial |
$5,486.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,242.56
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,230.88
|
| Rate for Payer: Cash Price |
$1,828.80
|
| Rate for Payer: Cigna Commercial |
$5,608.32
|
| Rate for Payer: Health EOS Commercial |
$5,425.44
|
| Rate for Payer: HFN Commercial |
$5,608.32
|
| Rate for Payer: Multiplan Commercial |
$4,876.80
|
| Rate for Payer: NAPHCARE Commercial |
$3,657.60
|
| Rate for Payer: Preferred Network Access Commercial |
$5,608.32
|
| Rate for Payer: Quartz Beloit One Network |
$2,987.04
|
| Rate for Payer: Quartz Commercial |
$3,657.60
|
| Rate for Payer: WEA Trust Commercial |
$3,352.80
|
| Rate for Payer: WPS Commercial |
$4,515.31
|
|
|
INSERT TRIDENT 0 DEG 40MM F 623-00-40F
|
Facility
|
OP
|
$6,096.00
|
|
| Hospital Charge Code |
3779520
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,706.88 |
| Max. Negotiated Rate |
$24,384.00 |
| Rate for Payer: Aetna Commercial |
$5,486.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,242.56
|
| Rate for Payer: Aetna Managed Medicare |
$1,706.88
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,962.40
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,048.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,926.08
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,230.88
|
| Rate for Payer: Cash Price |
$1,828.80
|
| Rate for Payer: Cigna Commercial |
$5,608.32
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,411.32
|
| Rate for Payer: Health EOS Commercial |
$5,425.44
|
| Rate for Payer: HFN Commercial |
$5,608.32
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,572.00
|
| Rate for Payer: Multiplan Commercial |
$4,876.80
|
| Rate for Payer: NAPHCARE Commercial |
$3,657.60
|
| Rate for Payer: Preferred Network Access Commercial |
$5,608.32
|
| Rate for Payer: Quartz Beloit One Network |
$2,987.04
|
| Rate for Payer: Quartz Commercial |
$3,962.40
|
| Rate for Payer: Quartz Medicare Advantage |
$3,657.60
|
| Rate for Payer: The Alliance Commercial |
$24,384.00
|
| Rate for Payer: WEA Trust Commercial |
$3,352.80
|
| Rate for Payer: WPS Commercial |
$4,515.31
|
|
|
INSERT TRIDENT 0 DEG 40MM G 623-00-40G
|
Facility
|
IP
|
$6,096.00
|
|
| Hospital Charge Code |
4519928
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,987.04 |
| Max. Negotiated Rate |
$5,608.32 |
| Rate for Payer: Aetna Commercial |
$5,486.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,242.56
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,230.88
|
| Rate for Payer: Cash Price |
$1,828.80
|
| Rate for Payer: Cigna Commercial |
$5,608.32
|
| Rate for Payer: Health EOS Commercial |
$5,425.44
|
| Rate for Payer: HFN Commercial |
$5,608.32
|
| Rate for Payer: Multiplan Commercial |
$4,876.80
|
| Rate for Payer: NAPHCARE Commercial |
$3,657.60
|
| Rate for Payer: Preferred Network Access Commercial |
$5,608.32
|
| Rate for Payer: Quartz Beloit One Network |
$2,987.04
|
| Rate for Payer: Quartz Commercial |
$3,657.60
|
| Rate for Payer: WEA Trust Commercial |
$3,352.80
|
| Rate for Payer: WPS Commercial |
$4,515.31
|
|
|
INSERT TRIDENT 0 DEG 40MM G 623-00-40G
|
Facility
|
OP
|
$6,096.00
|
|
| Hospital Charge Code |
4519928
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,706.88 |
| Max. Negotiated Rate |
$24,384.00 |
| Rate for Payer: Aetna Commercial |
$5,486.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,242.56
|
| Rate for Payer: Aetna Managed Medicare |
$1,706.88
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,962.40
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,048.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,926.08
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,230.88
|
| Rate for Payer: Cash Price |
$1,828.80
|
| Rate for Payer: Cigna Commercial |
$5,608.32
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,411.32
|
| Rate for Payer: Health EOS Commercial |
$5,425.44
|
| Rate for Payer: HFN Commercial |
$5,608.32
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,572.00
|
| Rate for Payer: Multiplan Commercial |
$4,876.80
|
| Rate for Payer: NAPHCARE Commercial |
$3,657.60
|
| Rate for Payer: Preferred Network Access Commercial |
$5,608.32
|
| Rate for Payer: Quartz Beloit One Network |
$2,987.04
|
| Rate for Payer: Quartz Commercial |
$3,962.40
|
| Rate for Payer: Quartz Medicare Advantage |
$3,657.60
|
| Rate for Payer: The Alliance Commercial |
$24,384.00
|
| Rate for Payer: WEA Trust Commercial |
$3,352.80
|
| Rate for Payer: WPS Commercial |
$4,515.31
|
|
|
INSERT TRIDENT 0 DEG 44MM F 623-00-44F
|
Facility
|
IP
|
$6,096.00
|
|
| Hospital Charge Code |
4263459
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,987.04 |
| Max. Negotiated Rate |
$5,608.32 |
| Rate for Payer: Aetna Commercial |
$5,486.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,242.56
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,230.88
|
| Rate for Payer: Cash Price |
$1,828.80
|
| Rate for Payer: Cigna Commercial |
$5,608.32
|
| Rate for Payer: Health EOS Commercial |
$5,425.44
|
| Rate for Payer: HFN Commercial |
$5,608.32
|
| Rate for Payer: Multiplan Commercial |
$4,876.80
|
| Rate for Payer: NAPHCARE Commercial |
$3,657.60
|
| Rate for Payer: Preferred Network Access Commercial |
$5,608.32
|
| Rate for Payer: Quartz Beloit One Network |
$2,987.04
|
| Rate for Payer: Quartz Commercial |
$3,657.60
|
| Rate for Payer: WEA Trust Commercial |
$3,352.80
|
| Rate for Payer: WPS Commercial |
$4,515.31
|
|
|
INSERT TRIDENT 0 DEG 44MM F 623-00-44F
|
Facility
|
OP
|
$6,096.00
|
|
| Hospital Charge Code |
4263459
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,706.88 |
| Max. Negotiated Rate |
$24,384.00 |
| Rate for Payer: Aetna Commercial |
$5,486.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,242.56
|
| Rate for Payer: Aetna Managed Medicare |
$1,706.88
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,962.40
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,048.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,926.08
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,230.88
|
| Rate for Payer: Cash Price |
$1,828.80
|
| Rate for Payer: Cigna Commercial |
$5,608.32
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,411.32
|
| Rate for Payer: Health EOS Commercial |
$5,425.44
|
| Rate for Payer: HFN Commercial |
$5,608.32
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,572.00
|
| Rate for Payer: Multiplan Commercial |
$4,876.80
|
| Rate for Payer: NAPHCARE Commercial |
$3,657.60
|
| Rate for Payer: Preferred Network Access Commercial |
$5,608.32
|
| Rate for Payer: Quartz Beloit One Network |
$2,987.04
|
| Rate for Payer: Quartz Commercial |
$3,962.40
|
| Rate for Payer: Quartz Medicare Advantage |
$3,657.60
|
| Rate for Payer: The Alliance Commercial |
$24,384.00
|
| Rate for Payer: WEA Trust Commercial |
$3,352.80
|
| Rate for Payer: WPS Commercial |
$4,515.31
|
|
|
INSERT TRIDENT 0 DEG 44MM G 623-00-44G
|
Facility
|
OP
|
$6,096.00
|
|
| Hospital Charge Code |
4508738
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,706.88 |
| Max. Negotiated Rate |
$24,384.00 |
| Rate for Payer: Aetna Commercial |
$5,486.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,242.56
|
| Rate for Payer: Aetna Managed Medicare |
$1,706.88
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,962.40
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,048.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,926.08
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,230.88
|
| Rate for Payer: Cash Price |
$1,828.80
|
| Rate for Payer: Cigna Commercial |
$5,608.32
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,411.32
|
| Rate for Payer: Health EOS Commercial |
$5,425.44
|
| Rate for Payer: HFN Commercial |
$5,608.32
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,572.00
|
| Rate for Payer: Multiplan Commercial |
$4,876.80
|
| Rate for Payer: NAPHCARE Commercial |
$3,657.60
|
| Rate for Payer: Preferred Network Access Commercial |
$5,608.32
|
| Rate for Payer: Quartz Beloit One Network |
$2,987.04
|
| Rate for Payer: Quartz Commercial |
$3,962.40
|
| Rate for Payer: Quartz Medicare Advantage |
$3,657.60
|
| Rate for Payer: The Alliance Commercial |
$24,384.00
|
| Rate for Payer: WEA Trust Commercial |
$3,352.80
|
| Rate for Payer: WPS Commercial |
$4,515.31
|
|
|
INSERT TRIDENT 0 DEG 44MM G 623-00-44G
|
Facility
|
IP
|
$6,096.00
|
|
| Hospital Charge Code |
4508738
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,987.04 |
| Max. Negotiated Rate |
$5,608.32 |
| Rate for Payer: Aetna Commercial |
$5,486.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,242.56
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,230.88
|
| Rate for Payer: Cash Price |
$1,828.80
|
| Rate for Payer: Cigna Commercial |
$5,608.32
|
| Rate for Payer: Health EOS Commercial |
$5,425.44
|
| Rate for Payer: HFN Commercial |
$5,608.32
|
| Rate for Payer: Multiplan Commercial |
$4,876.80
|
| Rate for Payer: NAPHCARE Commercial |
$3,657.60
|
| Rate for Payer: Preferred Network Access Commercial |
$5,608.32
|
| Rate for Payer: Quartz Beloit One Network |
$2,987.04
|
| Rate for Payer: Quartz Commercial |
$3,657.60
|
| Rate for Payer: WEA Trust Commercial |
$3,352.80
|
| Rate for Payer: WPS Commercial |
$4,515.31
|
|
|
INSERT TRIDENT 10 DEG 32MM D 623-10-32D
|
Facility
|
OP
|
$6,096.00
|
|
| Hospital Charge Code |
3127481
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,706.88 |
| Max. Negotiated Rate |
$24,384.00 |
| Rate for Payer: Aetna Commercial |
$5,486.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,242.56
|
| Rate for Payer: Aetna Managed Medicare |
$1,706.88
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,962.40
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,048.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,926.08
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,230.88
|
| Rate for Payer: Cash Price |
$1,828.80
|
| Rate for Payer: Cigna Commercial |
$5,608.32
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,411.32
|
| Rate for Payer: Health EOS Commercial |
$5,425.44
|
| Rate for Payer: HFN Commercial |
$5,608.32
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,572.00
|
| Rate for Payer: Multiplan Commercial |
$4,876.80
|
| Rate for Payer: NAPHCARE Commercial |
$3,657.60
|
| Rate for Payer: Preferred Network Access Commercial |
$5,608.32
|
| Rate for Payer: Quartz Beloit One Network |
$2,987.04
|
| Rate for Payer: Quartz Commercial |
$3,962.40
|
| Rate for Payer: Quartz Medicare Advantage |
$3,657.60
|
| Rate for Payer: The Alliance Commercial |
$24,384.00
|
| Rate for Payer: WEA Trust Commercial |
$3,352.80
|
| Rate for Payer: WPS Commercial |
$4,515.31
|
|
|
INSERT TRIDENT 10 DEG 32MM D 623-10-32D
|
Facility
|
IP
|
$6,096.00
|
|
| Hospital Charge Code |
3127481
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,987.04 |
| Max. Negotiated Rate |
$5,608.32 |
| Rate for Payer: Aetna Commercial |
$5,486.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,242.56
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,230.88
|
| Rate for Payer: Cash Price |
$1,828.80
|
| Rate for Payer: Cigna Commercial |
$5,608.32
|
| Rate for Payer: Health EOS Commercial |
$5,425.44
|
| Rate for Payer: HFN Commercial |
$5,608.32
|
| Rate for Payer: Multiplan Commercial |
$4,876.80
|
| Rate for Payer: NAPHCARE Commercial |
$3,657.60
|
| Rate for Payer: Preferred Network Access Commercial |
$5,608.32
|
| Rate for Payer: Quartz Beloit One Network |
$2,987.04
|
| Rate for Payer: Quartz Commercial |
$3,657.60
|
| Rate for Payer: WEA Trust Commercial |
$3,352.80
|
| Rate for Payer: WPS Commercial |
$4,515.31
|
|
|
INSERT TRIDENT 10 DEG 36MM E 623-10-36E
|
Facility
|
IP
|
$6,332.00
|
|
| Hospital Charge Code |
3365517
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,102.68 |
| Max. Negotiated Rate |
$5,825.44 |
| Rate for Payer: Aetna Commercial |
$5,698.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,445.52
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,355.96
|
| Rate for Payer: Cash Price |
$1,899.60
|
| Rate for Payer: Cigna Commercial |
$5,825.44
|
| Rate for Payer: Health EOS Commercial |
$5,635.48
|
| Rate for Payer: HFN Commercial |
$5,825.44
|
| Rate for Payer: Multiplan Commercial |
$5,065.60
|
| Rate for Payer: NAPHCARE Commercial |
$3,799.20
|
| Rate for Payer: Preferred Network Access Commercial |
$5,825.44
|
| Rate for Payer: Quartz Beloit One Network |
$3,102.68
|
| Rate for Payer: Quartz Commercial |
$3,799.20
|
| Rate for Payer: WEA Trust Commercial |
$3,482.60
|
| Rate for Payer: WPS Commercial |
$4,690.11
|
|
|
INSERT TRIDENT 10 DEG 36MM E 623-10-36E
|
Facility
|
OP
|
$6,332.00
|
|
| Hospital Charge Code |
3365517
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,772.96 |
| Max. Negotiated Rate |
$25,328.00 |
| Rate for Payer: Aetna Commercial |
$5,698.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,445.52
|
| Rate for Payer: Aetna Managed Medicare |
$1,772.96
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,115.80
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,166.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,039.36
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,355.96
|
| Rate for Payer: Cash Price |
$1,899.60
|
| Rate for Payer: Cigna Commercial |
$5,825.44
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,543.39
|
| Rate for Payer: Health EOS Commercial |
$5,635.48
|
| Rate for Payer: HFN Commercial |
$5,825.44
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,749.00
|
| Rate for Payer: Multiplan Commercial |
$5,065.60
|
| Rate for Payer: NAPHCARE Commercial |
$3,799.20
|
| Rate for Payer: Preferred Network Access Commercial |
$5,825.44
|
| Rate for Payer: Quartz Beloit One Network |
$3,102.68
|
| Rate for Payer: Quartz Commercial |
$4,115.80
|
| Rate for Payer: Quartz Medicare Advantage |
$3,799.20
|
| Rate for Payer: The Alliance Commercial |
$25,328.00
|
| Rate for Payer: WEA Trust Commercial |
$3,482.60
|
| Rate for Payer: WPS Commercial |
$4,690.11
|
|
|
INSERT TRIDENT 10 DEG 36MM F 623-10-36F
|
Facility
|
OP
|
$7,603.00
|
|
| Hospital Charge Code |
3072475
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,128.84 |
| Max. Negotiated Rate |
$30,412.00 |
| Rate for Payer: Aetna Commercial |
$6,842.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,538.58
|
| Rate for Payer: Aetna Managed Medicare |
$2,128.84
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,941.95
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,801.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,649.44
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,029.59
|
| Rate for Payer: Cash Price |
$2,280.90
|
| Rate for Payer: Cigna Commercial |
$6,994.76
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,254.64
|
| Rate for Payer: Health EOS Commercial |
$6,766.67
|
| Rate for Payer: HFN Commercial |
$6,994.76
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5,702.25
|
| Rate for Payer: Multiplan Commercial |
$6,082.40
|
| Rate for Payer: NAPHCARE Commercial |
$4,561.80
|
| Rate for Payer: Preferred Network Access Commercial |
$6,994.76
|
| Rate for Payer: Quartz Beloit One Network |
$3,725.47
|
| Rate for Payer: Quartz Commercial |
$4,941.95
|
| Rate for Payer: Quartz Medicare Advantage |
$4,561.80
|
| Rate for Payer: The Alliance Commercial |
$30,412.00
|
| Rate for Payer: WEA Trust Commercial |
$4,181.65
|
| Rate for Payer: WPS Commercial |
$5,631.54
|
|
|
INSERT TRIDENT 10 DEG 36MM F 623-10-36F
|
Facility
|
IP
|
$7,603.00
|
|
| Hospital Charge Code |
3072475
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,725.47 |
| Max. Negotiated Rate |
$6,994.76 |
| Rate for Payer: Aetna Commercial |
$6,842.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,538.58
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,029.59
|
| Rate for Payer: Cash Price |
$2,280.90
|
| Rate for Payer: Cigna Commercial |
$6,994.76
|
| Rate for Payer: Health EOS Commercial |
$6,766.67
|
| Rate for Payer: HFN Commercial |
$6,994.76
|
| Rate for Payer: Multiplan Commercial |
$6,082.40
|
| Rate for Payer: NAPHCARE Commercial |
$4,561.80
|
| Rate for Payer: Preferred Network Access Commercial |
$6,994.76
|
| Rate for Payer: Quartz Beloit One Network |
$3,725.47
|
| Rate for Payer: Quartz Commercial |
$4,561.80
|
| Rate for Payer: WEA Trust Commercial |
$4,181.65
|
| Rate for Payer: WPS Commercial |
$5,631.54
|
|
|
INSERT TRIDENT 10 DEG 36MM G 623-10-36G
|
Facility
|
IP
|
$6,450.00
|
|
| Hospital Charge Code |
5179170
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,160.50 |
| Max. Negotiated Rate |
$5,934.00 |
| Rate for Payer: Aetna Commercial |
$5,805.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,547.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,418.50
|
| Rate for Payer: Cash Price |
$1,935.00
|
| Rate for Payer: Cigna Commercial |
$5,934.00
|
| Rate for Payer: Health EOS Commercial |
$5,740.50
|
| Rate for Payer: HFN Commercial |
$5,934.00
|
| Rate for Payer: Multiplan Commercial |
$5,160.00
|
| Rate for Payer: NAPHCARE Commercial |
$3,870.00
|
| Rate for Payer: Preferred Network Access Commercial |
$5,934.00
|
| Rate for Payer: Quartz Beloit One Network |
$3,160.50
|
| Rate for Payer: Quartz Commercial |
$3,870.00
|
| Rate for Payer: WEA Trust Commercial |
$3,547.50
|
| Rate for Payer: WPS Commercial |
$4,777.52
|
|
|
INSERT TRIDENT 10 DEG 36MM G 623-10-36G
|
Facility
|
OP
|
$6,450.00
|
|
| Hospital Charge Code |
5179170
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,806.00 |
| Max. Negotiated Rate |
$25,800.00 |
| Rate for Payer: Aetna Commercial |
$5,805.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,547.00
|
| Rate for Payer: Aetna Managed Medicare |
$1,806.00
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,192.50
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,225.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,096.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,418.50
|
| Rate for Payer: Cash Price |
$1,935.00
|
| Rate for Payer: Cigna Commercial |
$5,934.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,609.42
|
| Rate for Payer: Health EOS Commercial |
$5,740.50
|
| Rate for Payer: HFN Commercial |
$5,934.00
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,837.50
|
| Rate for Payer: Multiplan Commercial |
$5,160.00
|
| Rate for Payer: NAPHCARE Commercial |
$3,870.00
|
| Rate for Payer: Preferred Network Access Commercial |
$5,934.00
|
| Rate for Payer: Quartz Beloit One Network |
$3,160.50
|
| Rate for Payer: Quartz Commercial |
$4,192.50
|
| Rate for Payer: Quartz Medicare Advantage |
$3,870.00
|
| Rate for Payer: The Alliance Commercial |
$25,800.00
|
| Rate for Payer: WEA Trust Commercial |
$3,547.50
|
| Rate for Payer: WPS Commercial |
$4,777.52
|
|
|
INSERT TRIDENT X3 POLYETHYLENE 0DEG 36MM 723-00-36D
|
Facility
|
OP
|
$6,384.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
6212958
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,787.52 |
| Max. Negotiated Rate |
$25,536.00 |
| Rate for Payer: Aetna Commercial |
$5,745.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,490.24
|
| Rate for Payer: Aetna Managed Medicare |
$1,787.52
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,149.60
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,192.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,064.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,383.52
|
| Rate for Payer: Cash Price |
$1,915.20
|
| Rate for Payer: Cigna Commercial |
$5,873.28
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,572.49
|
| Rate for Payer: Health EOS Commercial |
$5,681.76
|
| Rate for Payer: HFN Commercial |
$5,873.28
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,788.00
|
| Rate for Payer: Multiplan Commercial |
$5,107.20
|
| Rate for Payer: NAPHCARE Commercial |
$3,830.40
|
| Rate for Payer: Preferred Network Access Commercial |
$5,873.28
|
| Rate for Payer: Quartz Beloit One Network |
$3,128.16
|
| Rate for Payer: Quartz Commercial |
$4,149.60
|
| Rate for Payer: Quartz Medicare Advantage |
$3,830.40
|
| Rate for Payer: The Alliance Commercial |
$25,536.00
|
| Rate for Payer: WEA Trust Commercial |
$3,511.20
|
| Rate for Payer: WPS Commercial |
$4,728.63
|
|
|
INSERT TRIDENT X3 POLYETHYLENE 0DEG 36MM 723-00-36D
|
Facility
|
IP
|
$6,384.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
6212958
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,128.16 |
| Max. Negotiated Rate |
$5,873.28 |
| Rate for Payer: Aetna Commercial |
$5,745.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,490.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,383.52
|
| Rate for Payer: Cash Price |
$1,915.20
|
| Rate for Payer: Cigna Commercial |
$5,873.28
|
| Rate for Payer: Health EOS Commercial |
$5,681.76
|
| Rate for Payer: HFN Commercial |
$5,873.28
|
| Rate for Payer: Multiplan Commercial |
$5,107.20
|
| Rate for Payer: NAPHCARE Commercial |
$3,830.40
|
| Rate for Payer: Preferred Network Access Commercial |
$5,873.28
|
| Rate for Payer: Quartz Beloit One Network |
$3,128.16
|
| Rate for Payer: Quartz Commercial |
$3,830.40
|
| Rate for Payer: WEA Trust Commercial |
$3,511.20
|
| Rate for Payer: WPS Commercial |
$4,728.63
|
|
|
INSERT TUNNELED CV CATH 36558
|
Professional
|
Both
|
$3,724.00
|
|
|
Service Code
|
CPT 36558
|
| Hospital Charge Code |
3014532
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$671.07 |
| Max. Negotiated Rate |
$3,537.80 |
| Rate for Payer: Aetna Commercial |
$3,537.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,202.64
|
| Rate for Payer: Cash Price |
$1,117.20
|
| Rate for Payer: Cash Price |
$1,117.20
|
| Rate for Payer: Cash Price |
$1,117.20
|
| Rate for Payer: Cigna Commercial |
$3,537.80
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$671.07
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,234.40
|
| Rate for Payer: Health EOS Commercial |
$3,388.84
|
| Rate for Payer: HFN Commercial |
$3,537.80
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$862.59
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$862.59
|
| Rate for Payer: Multiplan Commercial |
$2,979.20
|
| Rate for Payer: Preferred Network Access Commercial |
$3,537.80
|
| Rate for Payer: Quartz Beloit One Network |
$1,638.56
|
| Rate for Payer: Quartz Commercial |
$2,122.68
|
| Rate for Payer: The Alliance Commercial |
$1,862.00
|
| Rate for Payer: United Healthcare Medicaid |
$671.07
|
| Rate for Payer: WEA Trust Commercial |
$2,048.20
|
| Rate for Payer: WPS Commercial |
$2,758.37
|
|
|
INSERT TUNNELED CV CATH 3655822
|
Professional
|
Both
|
$4,471.00
|
|
|
Service Code
|
CPT 36558 22
|
| Hospital Charge Code |
5190612
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$671.07 |
| Max. Negotiated Rate |
$4,247.45 |
| Rate for Payer: Aetna Commercial |
$4,247.45
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,845.06
|
| Rate for Payer: Cash Price |
$1,341.30
|
| Rate for Payer: Cash Price |
$1,341.30
|
| Rate for Payer: Cash Price |
$1,341.30
|
| Rate for Payer: Cigna Commercial |
$4,247.45
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$671.07
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,682.60
|
| Rate for Payer: Health EOS Commercial |
$4,068.61
|
| Rate for Payer: HFN Commercial |
$4,247.45
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$862.59
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$862.59
|
| Rate for Payer: Multiplan Commercial |
$3,576.80
|
| Rate for Payer: Preferred Network Access Commercial |
$4,247.45
|
| Rate for Payer: Quartz Beloit One Network |
$1,967.24
|
| Rate for Payer: Quartz Commercial |
$2,548.47
|
| Rate for Payer: The Alliance Commercial |
$2,235.50
|
| Rate for Payer: United Healthcare Medicaid |
$671.07
|
| Rate for Payer: WEA Trust Commercial |
$2,459.05
|
| Rate for Payer: WPS Commercial |
$3,311.67
|
|
