|
LIGATION OR BIOPSY, TEMPORAL ARTERY
|
Facility
|
OP
|
$6,409.96
|
|
|
Service Code
|
CPT 37609
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,602.49 |
| Max. Negotiated Rate |
$6,409.96 |
| Rate for Payer: Aetna Managed Medicare |
$1,602.49
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,496.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,871.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,726.00
|
| Rate for Payer: Anthem Medicare Advantage |
$1,602.49
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$1,602.49
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$1,602.49
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$1,602.49
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,757.59
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$1,602.49
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5,961.26
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$1,602.49
|
| Rate for Payer: Independent Care Health Plan Medicare |
$1,602.49
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$1,602.49
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$1,602.49
|
| Rate for Payer: NAPHCARE Commercial |
$2,403.74
|
| Rate for Payer: Quartz Medicare Advantage |
$1,602.49
|
| Rate for Payer: The Alliance Commercial |
$6,409.96
|
| Rate for Payer: United Healthcare Medicare Advantage |
$1,602.49
|
| Rate for Payer: United Healthcare PPO |
$3,583.00
|
| Rate for Payer: Wellcare Medicare |
$1,602.49
|
|
|
Liletta 1 unit Charge
|
Facility
|
IP
|
$1,892.00
|
|
|
Service Code
|
HCPCS J7297
|
| Hospital Charge Code |
5571267
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$927.08 |
| Max. Negotiated Rate |
$1,740.64 |
| Rate for Payer: Aetna Commercial |
$1,702.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,627.12
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,002.76
|
| Rate for Payer: Cash Price |
$567.60
|
| Rate for Payer: Cigna Commercial |
$1,740.64
|
| Rate for Payer: Health EOS Commercial |
$1,683.88
|
| Rate for Payer: HFN Commercial |
$1,740.64
|
| Rate for Payer: Multiplan Commercial |
$1,513.60
|
| Rate for Payer: NAPHCARE Commercial |
$1,135.20
|
| Rate for Payer: Preferred Network Access Commercial |
$1,740.64
|
| Rate for Payer: Quartz Beloit One Network |
$927.08
|
| Rate for Payer: Quartz Commercial |
$1,135.20
|
| Rate for Payer: WEA Trust Commercial |
$1,040.60
|
| Rate for Payer: WPS Commercial |
$1,401.40
|
|
|
Liletta 1 unit Charge
|
Facility
|
OP
|
$1,892.00
|
|
|
Service Code
|
HCPCS J7297
|
| Hospital Charge Code |
5571267
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$529.76 |
| Max. Negotiated Rate |
$7,568.00 |
| Rate for Payer: Aetna Commercial |
$1,702.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,627.12
|
| Rate for Payer: Aetna Managed Medicare |
$529.76
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,229.80
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$946.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$908.16
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,002.76
|
| Rate for Payer: Cash Price |
$567.60
|
| Rate for Payer: Cigna Commercial |
$1,740.64
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,058.76
|
| Rate for Payer: Health EOS Commercial |
$1,683.88
|
| Rate for Payer: HFN Commercial |
$1,740.64
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,419.00
|
| Rate for Payer: Multiplan Commercial |
$1,513.60
|
| Rate for Payer: NAPHCARE Commercial |
$1,135.20
|
| Rate for Payer: Preferred Network Access Commercial |
$1,740.64
|
| Rate for Payer: Quartz Beloit One Network |
$927.08
|
| Rate for Payer: Quartz Commercial |
$1,229.80
|
| Rate for Payer: Quartz Medicare Advantage |
$1,135.20
|
| Rate for Payer: The Alliance Commercial |
$7,568.00
|
| Rate for Payer: WEA Trust Commercial |
$1,040.60
|
| Rate for Payer: WPS Commercial |
$1,401.40
|
|
|
Liletta 1 unit Charge
|
Professional
|
Both
|
$1,892.00
|
|
|
Service Code
|
HCPCS J7297
|
| Hospital Charge Code |
5571267
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$832.48 |
| Max. Negotiated Rate |
$1,797.40 |
| Rate for Payer: Aetna Commercial |
$1,797.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,627.12
|
| Rate for Payer: Anthem Commercial |
$845.10
|
| Rate for Payer: Cash Price |
$567.60
|
| Rate for Payer: Cash Price |
$567.60
|
| Rate for Payer: Cigna Commercial |
$1,797.40
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$845.10
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,135.20
|
| Rate for Payer: Health EOS Commercial |
$1,721.72
|
| Rate for Payer: HFN Commercial |
$1,797.40
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,264.70
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$1,264.70
|
| Rate for Payer: Multiplan Commercial |
$1,513.60
|
| Rate for Payer: Preferred Network Access Commercial |
$1,797.40
|
| Rate for Payer: Quartz Beloit One Network |
$832.48
|
| Rate for Payer: Quartz Commercial |
$1,078.44
|
| Rate for Payer: The Alliance Commercial |
$946.00
|
| Rate for Payer: United Healthcare Medicaid |
$845.10
|
| Rate for Payer: WEA Trust Commercial |
$1,040.60
|
| Rate for Payer: WPS Commercial |
$1,401.40
|
|
|
LIMB REATTACHMENT, HIP AND FEMUR PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA
|
Facility
|
IP
|
$103,426.00
|
|
|
Service Code
|
MSDRG 956
|
| Min. Negotiated Rate |
$37,203.63 |
| Max. Negotiated Rate |
$103,426.00 |
| Rate for Payer: Aetna Managed Medicare |
$37,203.63
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$81,402.40
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$62,394.28
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$59,278.64
|
| Rate for Payer: Anthem Medicare Advantage |
$37,203.63
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$37,203.63
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$37,203.63
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$37,203.63
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$65,804.72
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$37,203.63
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$75,624.90
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$37,203.63
|
| Rate for Payer: Independent Care Health Plan Medicare |
$37,203.63
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$37,203.63
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$37,203.63
|
| Rate for Payer: NAPHCARE Commercial |
$55,805.44
|
| Rate for Payer: Quartz Medicare Advantage |
$37,203.63
|
| Rate for Payer: The Alliance Commercial |
$103,426.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$37,203.63
|
| Rate for Payer: United Healthcare PPO |
$58,874.95
|
| Rate for Payer: Wellcare Medicare |
$37,203.63
|
|
|
LINEAR IAB KIT - 34CC 7.5FR
|
Facility
|
IP
|
$8,800.00
|
|
|
Service Code
|
HCPCS C2628
|
| Hospital Charge Code |
2973759
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$4,312.00 |
| Max. Negotiated Rate |
$8,096.00 |
| Rate for Payer: Aetna Commercial |
$7,920.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,568.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,664.00
|
| Rate for Payer: Cash Price |
$2,640.00
|
| Rate for Payer: Cigna Commercial |
$8,096.00
|
| Rate for Payer: Health EOS Commercial |
$7,832.00
|
| Rate for Payer: HFN Commercial |
$8,096.00
|
| Rate for Payer: Multiplan Commercial |
$7,040.00
|
| Rate for Payer: NAPHCARE Commercial |
$5,280.00
|
| Rate for Payer: Preferred Network Access Commercial |
$8,096.00
|
| Rate for Payer: Quartz Beloit One Network |
$4,312.00
|
| Rate for Payer: Quartz Commercial |
$5,280.00
|
| Rate for Payer: WEA Trust Commercial |
$4,840.00
|
| Rate for Payer: WPS Commercial |
$6,518.16
|
|
|
LINEAR IAB KIT - 34CC 7.5FR
|
Facility
|
OP
|
$8,800.00
|
|
|
Service Code
|
HCPCS C2628
|
| Hospital Charge Code |
2973759
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$2,464.00 |
| Max. Negotiated Rate |
$35,200.00 |
| Rate for Payer: Aetna Commercial |
$7,920.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,568.00
|
| Rate for Payer: Aetna Managed Medicare |
$2,464.00
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5,720.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,400.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,224.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,664.00
|
| Rate for Payer: Cash Price |
$2,640.00
|
| Rate for Payer: Cigna Commercial |
$8,096.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,924.48
|
| Rate for Payer: Health EOS Commercial |
$7,832.00
|
| Rate for Payer: HFN Commercial |
$8,096.00
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$6,600.00
|
| Rate for Payer: Multiplan Commercial |
$7,040.00
|
| Rate for Payer: NAPHCARE Commercial |
$5,280.00
|
| Rate for Payer: Preferred Network Access Commercial |
$8,096.00
|
| Rate for Payer: Quartz Beloit One Network |
$4,312.00
|
| Rate for Payer: Quartz Commercial |
$5,720.00
|
| Rate for Payer: Quartz Medicare Advantage |
$5,280.00
|
| Rate for Payer: The Alliance Commercial |
$35,200.00
|
| Rate for Payer: WEA Trust Commercial |
$4,840.00
|
| Rate for Payer: WPS Commercial |
$6,518.16
|
|
|
LINE IV FLUID FAS1272
|
Facility
|
OP
|
$80.00
|
|
| Hospital Charge Code |
2972097
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$22.40 |
| Max. Negotiated Rate |
$320.00 |
| Rate for Payer: Aetna Commercial |
$72.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$68.80
|
| Rate for Payer: Aetna Managed Medicare |
$22.40
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$52.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$40.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$38.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$42.40
|
| Rate for Payer: Cash Price |
$24.00
|
| Rate for Payer: Cigna Commercial |
$73.60
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$44.77
|
| Rate for Payer: Health EOS Commercial |
$71.20
|
| Rate for Payer: HFN Commercial |
$73.60
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$60.00
|
| Rate for Payer: Multiplan Commercial |
$64.00
|
| Rate for Payer: NAPHCARE Commercial |
$48.00
|
| Rate for Payer: Preferred Network Access Commercial |
$73.60
|
| Rate for Payer: Quartz Beloit One Network |
$39.20
|
| Rate for Payer: Quartz Commercial |
$52.00
|
| Rate for Payer: Quartz Medicare Advantage |
$48.00
|
| Rate for Payer: The Alliance Commercial |
$320.00
|
| Rate for Payer: WEA Trust Commercial |
$44.00
|
| Rate for Payer: WPS Commercial |
$59.26
|
|
|
LINE IV FLUID FAS1272
|
Facility
|
IP
|
$80.00
|
|
| Hospital Charge Code |
2972097
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$39.20 |
| Max. Negotiated Rate |
$73.60 |
| Rate for Payer: Aetna Commercial |
$72.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$68.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$42.40
|
| Rate for Payer: Cash Price |
$24.00
|
| Rate for Payer: Cigna Commercial |
$73.60
|
| Rate for Payer: Health EOS Commercial |
$71.20
|
| Rate for Payer: HFN Commercial |
$73.60
|
| Rate for Payer: Multiplan Commercial |
$64.00
|
| Rate for Payer: NAPHCARE Commercial |
$48.00
|
| Rate for Payer: Preferred Network Access Commercial |
$73.60
|
| Rate for Payer: Quartz Beloit One Network |
$39.20
|
| Rate for Payer: Quartz Commercial |
$48.00
|
| Rate for Payer: WEA Trust Commercial |
$44.00
|
| Rate for Payer: WPS Commercial |
$59.26
|
|
|
LINER 1000CC SUCTION CANISTER 71-6510
|
Facility
|
IP
|
$84.00
|
|
| Hospital Charge Code |
2963198
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$41.16 |
| Max. Negotiated Rate |
$77.28 |
| Rate for Payer: Aetna Commercial |
$75.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$72.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$44.52
|
| Rate for Payer: Cash Price |
$25.20
|
| Rate for Payer: Cigna Commercial |
$77.28
|
| Rate for Payer: Health EOS Commercial |
$74.76
|
| Rate for Payer: HFN Commercial |
$77.28
|
| Rate for Payer: Multiplan Commercial |
$67.20
|
| Rate for Payer: NAPHCARE Commercial |
$50.40
|
| Rate for Payer: Preferred Network Access Commercial |
$77.28
|
| Rate for Payer: Quartz Beloit One Network |
$41.16
|
| Rate for Payer: Quartz Commercial |
$50.40
|
| Rate for Payer: WEA Trust Commercial |
$46.20
|
| Rate for Payer: WPS Commercial |
$62.22
|
|
|
LINER 1000CC SUCTION CANISTER 71-6510
|
Facility
|
OP
|
$84.00
|
|
| Hospital Charge Code |
2963198
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$23.52 |
| Max. Negotiated Rate |
$336.00 |
| Rate for Payer: Aetna Commercial |
$75.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$72.24
|
| Rate for Payer: Aetna Managed Medicare |
$23.52
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$54.60
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$42.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$40.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$44.52
|
| Rate for Payer: Cash Price |
$25.20
|
| Rate for Payer: Cigna Commercial |
$77.28
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$47.01
|
| Rate for Payer: Health EOS Commercial |
$74.76
|
| Rate for Payer: HFN Commercial |
$77.28
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$63.00
|
| Rate for Payer: Multiplan Commercial |
$67.20
|
| Rate for Payer: NAPHCARE Commercial |
$50.40
|
| Rate for Payer: Preferred Network Access Commercial |
$77.28
|
| Rate for Payer: Quartz Beloit One Network |
$41.16
|
| Rate for Payer: Quartz Commercial |
$54.60
|
| Rate for Payer: Quartz Medicare Advantage |
$50.40
|
| Rate for Payer: The Alliance Commercial |
$336.00
|
| Rate for Payer: WEA Trust Commercial |
$46.20
|
| Rate for Payer: WPS Commercial |
$62.22
|
|
|
LINER 3000CC SUCTION CANISTER QTXHESL3000B
|
Facility
|
IP
|
$81.00
|
|
|
Service Code
|
HCPCS A7000
|
| Hospital Charge Code |
2962822
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$39.69 |
| Max. Negotiated Rate |
$74.52 |
| Rate for Payer: Aetna Commercial |
$72.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$69.66
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$42.93
|
| Rate for Payer: Cash Price |
$24.30
|
| Rate for Payer: Cigna Commercial |
$74.52
|
| Rate for Payer: Health EOS Commercial |
$72.09
|
| Rate for Payer: HFN Commercial |
$74.52
|
| Rate for Payer: Multiplan Commercial |
$64.80
|
| Rate for Payer: NAPHCARE Commercial |
$48.60
|
| Rate for Payer: Preferred Network Access Commercial |
$74.52
|
| Rate for Payer: Quartz Beloit One Network |
$39.69
|
| Rate for Payer: Quartz Commercial |
$48.60
|
| Rate for Payer: WEA Trust Commercial |
$44.55
|
| Rate for Payer: WPS Commercial |
$60.00
|
|
|
LINER 3000CC SUCTION CANISTER QTXHESL3000B
|
Facility
|
OP
|
$81.00
|
|
|
Service Code
|
HCPCS A7000
|
| Hospital Charge Code |
2962822
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$22.68 |
| Max. Negotiated Rate |
$324.00 |
| Rate for Payer: Aetna Commercial |
$72.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$69.66
|
| Rate for Payer: Aetna Managed Medicare |
$22.68
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$52.65
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$40.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$38.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$42.93
|
| Rate for Payer: Cash Price |
$24.30
|
| Rate for Payer: Cigna Commercial |
$74.52
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$45.33
|
| Rate for Payer: Health EOS Commercial |
$72.09
|
| Rate for Payer: HFN Commercial |
$74.52
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$60.75
|
| Rate for Payer: Multiplan Commercial |
$64.80
|
| Rate for Payer: NAPHCARE Commercial |
$48.60
|
| Rate for Payer: Preferred Network Access Commercial |
$74.52
|
| Rate for Payer: Quartz Beloit One Network |
$39.69
|
| Rate for Payer: Quartz Commercial |
$52.65
|
| Rate for Payer: Quartz Medicare Advantage |
$48.60
|
| Rate for Payer: The Alliance Commercial |
$324.00
|
| Rate for Payer: WEA Trust Commercial |
$44.55
|
| Rate for Payer: WPS Commercial |
$60.00
|
|
|
LINER 36X50/52/54 LONGEVITY STD 6305-50-36
|
Facility
|
OP
|
$9,973.00
|
|
| Hospital Charge Code |
2967748
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,792.44 |
| Max. Negotiated Rate |
$39,892.00 |
| Rate for Payer: Aetna Commercial |
$8,975.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$8,576.78
|
| Rate for Payer: Aetna Managed Medicare |
$2,792.44
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$6,482.45
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,986.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,787.04
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,285.69
|
| Rate for Payer: Cash Price |
$2,991.90
|
| Rate for Payer: Cigna Commercial |
$9,175.16
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$5,580.89
|
| Rate for Payer: Health EOS Commercial |
$8,875.97
|
| Rate for Payer: HFN Commercial |
$9,175.16
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$7,479.75
|
| Rate for Payer: Multiplan Commercial |
$7,978.40
|
| Rate for Payer: NAPHCARE Commercial |
$5,983.80
|
| Rate for Payer: Preferred Network Access Commercial |
$9,175.16
|
| Rate for Payer: Quartz Beloit One Network |
$4,886.77
|
| Rate for Payer: Quartz Commercial |
$6,482.45
|
| Rate for Payer: Quartz Medicare Advantage |
$5,983.80
|
| Rate for Payer: The Alliance Commercial |
$39,892.00
|
| Rate for Payer: WEA Trust Commercial |
$5,485.15
|
| Rate for Payer: WPS Commercial |
$7,387.00
|
|
|
LINER 36X50/52/54 LONGEVITY STD 6305-50-36
|
Facility
|
IP
|
$9,973.00
|
|
| Hospital Charge Code |
2967748
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,886.77 |
| Max. Negotiated Rate |
$9,175.16 |
| Rate for Payer: Aetna Commercial |
$8,975.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$8,576.78
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,285.69
|
| Rate for Payer: Cash Price |
$2,991.90
|
| Rate for Payer: Cigna Commercial |
$9,175.16
|
| Rate for Payer: Health EOS Commercial |
$8,875.97
|
| Rate for Payer: HFN Commercial |
$9,175.16
|
| Rate for Payer: Multiplan Commercial |
$7,978.40
|
| Rate for Payer: NAPHCARE Commercial |
$5,983.80
|
| Rate for Payer: Preferred Network Access Commercial |
$9,175.16
|
| Rate for Payer: Quartz Beloit One Network |
$4,886.77
|
| Rate for Payer: Quartz Commercial |
$5,983.80
|
| Rate for Payer: WEA Trust Commercial |
$5,485.15
|
| Rate for Payer: WPS Commercial |
$7,387.00
|
|
|
LINER 36X56 LONGEVITY STD 6305-56-36
|
Facility
|
IP
|
$9,973.00
|
|
| Hospital Charge Code |
2967749
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,886.77 |
| Max. Negotiated Rate |
$9,175.16 |
| Rate for Payer: Aetna Commercial |
$8,975.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$8,576.78
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,285.69
|
| Rate for Payer: Cash Price |
$2,991.90
|
| Rate for Payer: Cigna Commercial |
$9,175.16
|
| Rate for Payer: Health EOS Commercial |
$8,875.97
|
| Rate for Payer: HFN Commercial |
$9,175.16
|
| Rate for Payer: Multiplan Commercial |
$7,978.40
|
| Rate for Payer: NAPHCARE Commercial |
$5,983.80
|
| Rate for Payer: Preferred Network Access Commercial |
$9,175.16
|
| Rate for Payer: Quartz Beloit One Network |
$4,886.77
|
| Rate for Payer: Quartz Commercial |
$5,983.80
|
| Rate for Payer: WEA Trust Commercial |
$5,485.15
|
| Rate for Payer: WPS Commercial |
$7,387.00
|
|
|
LINER 36X56 LONGEVITY STD 6305-56-36
|
Facility
|
OP
|
$9,973.00
|
|
| Hospital Charge Code |
2967749
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,792.44 |
| Max. Negotiated Rate |
$39,892.00 |
| Rate for Payer: Aetna Commercial |
$8,975.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$8,576.78
|
| Rate for Payer: Aetna Managed Medicare |
$2,792.44
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$6,482.45
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,986.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,787.04
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,285.69
|
| Rate for Payer: Cash Price |
$2,991.90
|
| Rate for Payer: Cigna Commercial |
$9,175.16
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$5,580.89
|
| Rate for Payer: Health EOS Commercial |
$8,875.97
|
| Rate for Payer: HFN Commercial |
$9,175.16
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$7,479.75
|
| Rate for Payer: Multiplan Commercial |
$7,978.40
|
| Rate for Payer: NAPHCARE Commercial |
$5,983.80
|
| Rate for Payer: Preferred Network Access Commercial |
$9,175.16
|
| Rate for Payer: Quartz Beloit One Network |
$4,886.77
|
| Rate for Payer: Quartz Commercial |
$6,482.45
|
| Rate for Payer: Quartz Medicare Advantage |
$5,983.80
|
| Rate for Payer: The Alliance Commercial |
$39,892.00
|
| Rate for Payer: WEA Trust Commercial |
$5,485.15
|
| Rate for Payer: WPS Commercial |
$7,387.00
|
|
|
LINER 36X58 10DEG LONGEVITY 6305-58-36
|
Facility
|
IP
|
$9,973.00
|
|
| Hospital Charge Code |
2967756
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,886.77 |
| Max. Negotiated Rate |
$9,175.16 |
| Rate for Payer: Aetna Commercial |
$8,975.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$8,576.78
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,285.69
|
| Rate for Payer: Cash Price |
$2,991.90
|
| Rate for Payer: Cigna Commercial |
$9,175.16
|
| Rate for Payer: Health EOS Commercial |
$8,875.97
|
| Rate for Payer: HFN Commercial |
$9,175.16
|
| Rate for Payer: Multiplan Commercial |
$7,978.40
|
| Rate for Payer: NAPHCARE Commercial |
$5,983.80
|
| Rate for Payer: Preferred Network Access Commercial |
$9,175.16
|
| Rate for Payer: Quartz Beloit One Network |
$4,886.77
|
| Rate for Payer: Quartz Commercial |
$5,983.80
|
| Rate for Payer: WEA Trust Commercial |
$5,485.15
|
| Rate for Payer: WPS Commercial |
$7,387.00
|
|
|
LINER 36X58 10DEG LONGEVITY 6305-58-36
|
Facility
|
OP
|
$9,973.00
|
|
| Hospital Charge Code |
2967756
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,792.44 |
| Max. Negotiated Rate |
$39,892.00 |
| Rate for Payer: Aetna Commercial |
$8,975.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$8,576.78
|
| Rate for Payer: Aetna Managed Medicare |
$2,792.44
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$6,482.45
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,986.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,787.04
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,285.69
|
| Rate for Payer: Cash Price |
$2,991.90
|
| Rate for Payer: Cigna Commercial |
$9,175.16
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$5,580.89
|
| Rate for Payer: Health EOS Commercial |
$8,875.97
|
| Rate for Payer: HFN Commercial |
$9,175.16
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$7,479.75
|
| Rate for Payer: Multiplan Commercial |
$7,978.40
|
| Rate for Payer: NAPHCARE Commercial |
$5,983.80
|
| Rate for Payer: Preferred Network Access Commercial |
$9,175.16
|
| Rate for Payer: Quartz Beloit One Network |
$4,886.77
|
| Rate for Payer: Quartz Commercial |
$6,482.45
|
| Rate for Payer: Quartz Medicare Advantage |
$5,983.80
|
| Rate for Payer: The Alliance Commercial |
$39,892.00
|
| Rate for Payer: WEA Trust Commercial |
$5,485.15
|
| Rate for Payer: WPS Commercial |
$7,387.00
|
|
|
LINER 36X60 10DEG LONGEVITY 6310-60-36
|
Facility
|
IP
|
$9,973.00
|
|
| Hospital Charge Code |
2967750
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,886.77 |
| Max. Negotiated Rate |
$9,175.16 |
| Rate for Payer: Aetna Commercial |
$8,975.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$8,576.78
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,285.69
|
| Rate for Payer: Cash Price |
$2,991.90
|
| Rate for Payer: Cigna Commercial |
$9,175.16
|
| Rate for Payer: Health EOS Commercial |
$8,875.97
|
| Rate for Payer: HFN Commercial |
$9,175.16
|
| Rate for Payer: Multiplan Commercial |
$7,978.40
|
| Rate for Payer: NAPHCARE Commercial |
$5,983.80
|
| Rate for Payer: Preferred Network Access Commercial |
$9,175.16
|
| Rate for Payer: Quartz Beloit One Network |
$4,886.77
|
| Rate for Payer: Quartz Commercial |
$5,983.80
|
| Rate for Payer: WEA Trust Commercial |
$5,485.15
|
| Rate for Payer: WPS Commercial |
$7,387.00
|
|
|
LINER 36X60 10DEG LONGEVITY 6310-60-36
|
Facility
|
OP
|
$9,973.00
|
|
| Hospital Charge Code |
2967750
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,792.44 |
| Max. Negotiated Rate |
$39,892.00 |
| Rate for Payer: Aetna Commercial |
$8,975.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$8,576.78
|
| Rate for Payer: Aetna Managed Medicare |
$2,792.44
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$6,482.45
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,986.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,787.04
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,285.69
|
| Rate for Payer: Cash Price |
$2,991.90
|
| Rate for Payer: Cigna Commercial |
$9,175.16
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$5,580.89
|
| Rate for Payer: Health EOS Commercial |
$8,875.97
|
| Rate for Payer: HFN Commercial |
$9,175.16
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$7,479.75
|
| Rate for Payer: Multiplan Commercial |
$7,978.40
|
| Rate for Payer: NAPHCARE Commercial |
$5,983.80
|
| Rate for Payer: Preferred Network Access Commercial |
$9,175.16
|
| Rate for Payer: Quartz Beloit One Network |
$4,886.77
|
| Rate for Payer: Quartz Commercial |
$6,482.45
|
| Rate for Payer: Quartz Medicare Advantage |
$5,983.80
|
| Rate for Payer: The Alliance Commercial |
$39,892.00
|
| Rate for Payer: WEA Trust Commercial |
$5,485.15
|
| Rate for Payer: WPS Commercial |
$7,387.00
|
|
|
LINER 36X62 10DEG LONGEVITY 6305-62-36
|
Facility
|
OP
|
$9,973.00
|
|
| Hospital Charge Code |
2967751
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,792.44 |
| Max. Negotiated Rate |
$39,892.00 |
| Rate for Payer: Aetna Commercial |
$8,975.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$8,576.78
|
| Rate for Payer: Aetna Managed Medicare |
$2,792.44
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$6,482.45
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,986.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,787.04
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,285.69
|
| Rate for Payer: Cash Price |
$2,991.90
|
| Rate for Payer: Cigna Commercial |
$9,175.16
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$5,580.89
|
| Rate for Payer: Health EOS Commercial |
$8,875.97
|
| Rate for Payer: HFN Commercial |
$9,175.16
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$7,479.75
|
| Rate for Payer: Multiplan Commercial |
$7,978.40
|
| Rate for Payer: NAPHCARE Commercial |
$5,983.80
|
| Rate for Payer: Preferred Network Access Commercial |
$9,175.16
|
| Rate for Payer: Quartz Beloit One Network |
$4,886.77
|
| Rate for Payer: Quartz Commercial |
$6,482.45
|
| Rate for Payer: Quartz Medicare Advantage |
$5,983.80
|
| Rate for Payer: The Alliance Commercial |
$39,892.00
|
| Rate for Payer: WEA Trust Commercial |
$5,485.15
|
| Rate for Payer: WPS Commercial |
$7,387.00
|
|
|
LINER 36X62 10DEG LONGEVITY 6305-62-36
|
Facility
|
IP
|
$9,973.00
|
|
| Hospital Charge Code |
2967751
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,886.77 |
| Max. Negotiated Rate |
$9,175.16 |
| Rate for Payer: Aetna Commercial |
$8,975.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$8,576.78
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,285.69
|
| Rate for Payer: Cash Price |
$2,991.90
|
| Rate for Payer: Cigna Commercial |
$9,175.16
|
| Rate for Payer: Health EOS Commercial |
$8,875.97
|
| Rate for Payer: HFN Commercial |
$9,175.16
|
| Rate for Payer: Multiplan Commercial |
$7,978.40
|
| Rate for Payer: NAPHCARE Commercial |
$5,983.80
|
| Rate for Payer: Preferred Network Access Commercial |
$9,175.16
|
| Rate for Payer: Quartz Beloit One Network |
$4,886.77
|
| Rate for Payer: Quartz Commercial |
$5,983.80
|
| Rate for Payer: WEA Trust Commercial |
$5,485.15
|
| Rate for Payer: WPS Commercial |
$7,387.00
|
|
|
LINER 36X64 10DEG LONGEVITY 6305-64-36
|
Facility
|
IP
|
$9,973.00
|
|
| Hospital Charge Code |
2967752
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,886.77 |
| Max. Negotiated Rate |
$9,175.16 |
| Rate for Payer: Aetna Commercial |
$8,975.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$8,576.78
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,285.69
|
| Rate for Payer: Cash Price |
$2,991.90
|
| Rate for Payer: Cigna Commercial |
$9,175.16
|
| Rate for Payer: Health EOS Commercial |
$8,875.97
|
| Rate for Payer: HFN Commercial |
$9,175.16
|
| Rate for Payer: Multiplan Commercial |
$7,978.40
|
| Rate for Payer: NAPHCARE Commercial |
$5,983.80
|
| Rate for Payer: Preferred Network Access Commercial |
$9,175.16
|
| Rate for Payer: Quartz Beloit One Network |
$4,886.77
|
| Rate for Payer: Quartz Commercial |
$5,983.80
|
| Rate for Payer: WEA Trust Commercial |
$5,485.15
|
| Rate for Payer: WPS Commercial |
$7,387.00
|
|
|
LINER 36X64 10DEG LONGEVITY 6305-64-36
|
Facility
|
OP
|
$9,973.00
|
|
| Hospital Charge Code |
2967752
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,792.44 |
| Max. Negotiated Rate |
$39,892.00 |
| Rate for Payer: Aetna Commercial |
$8,975.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$8,576.78
|
| Rate for Payer: Aetna Managed Medicare |
$2,792.44
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$6,482.45
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,986.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,787.04
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,285.69
|
| Rate for Payer: Cash Price |
$2,991.90
|
| Rate for Payer: Cigna Commercial |
$9,175.16
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$5,580.89
|
| Rate for Payer: Health EOS Commercial |
$8,875.97
|
| Rate for Payer: HFN Commercial |
$9,175.16
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$7,479.75
|
| Rate for Payer: Multiplan Commercial |
$7,978.40
|
| Rate for Payer: NAPHCARE Commercial |
$5,983.80
|
| Rate for Payer: Preferred Network Access Commercial |
$9,175.16
|
| Rate for Payer: Quartz Beloit One Network |
$4,886.77
|
| Rate for Payer: Quartz Commercial |
$6,482.45
|
| Rate for Payer: Quartz Medicare Advantage |
$5,983.80
|
| Rate for Payer: The Alliance Commercial |
$39,892.00
|
| Rate for Payer: WEA Trust Commercial |
$5,485.15
|
| Rate for Payer: WPS Commercial |
$7,387.00
|
|
