|
LINER 36 X 64 CONTIMUUM ELEV 00-8752-016-36
|
Facility
|
OP
|
$9,973.00
|
|
| Hospital Charge Code |
2967719
|
|
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 36 X 64 CONTIMUUM ELEV 00-8752-016-36
|
Facility
|
IP
|
$9,973.00
|
|
| Hospital Charge Code |
2967719
|
|
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 36X66 10DEG LONGEVITY 6305-66-36
|
Facility
|
IP
|
$9,973.00
|
|
| Hospital Charge Code |
2967753
|
|
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 36X66 10DEG LONGEVITY 6305-66-36
|
Facility
|
OP
|
$9,973.00
|
|
| Hospital Charge Code |
2967753
|
|
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 36 X 66 CONTINUUM ELEV 00-8752-017-36
|
Facility
|
IP
|
$9,973.00
|
|
| Hospital Charge Code |
2967720
|
|
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 36 X 66 CONTINUUM ELEV 00-8752-017-36
|
Facility
|
OP
|
$9,973.00
|
|
| Hospital Charge Code |
2967720
|
|
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 36X68 10DEG LONGEVITY 6305-68-36
|
Facility
|
OP
|
$9,973.00
|
|
| Hospital Charge Code |
2967754
|
|
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 36X68 10DEG LONGEVITY 6305-68-36
|
Facility
|
IP
|
$9,973.00
|
|
| Hospital Charge Code |
2967754
|
|
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 36 X 68 CONTINUUM ELEV 00-8752-018-36
|
Facility
|
IP
|
$9,973.00
|
|
| Hospital Charge Code |
2967721
|
|
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 36 X 68 CONTINUUM ELEV 00-8752-018-36
|
Facility
|
OP
|
$9,973.00
|
|
| Hospital Charge Code |
2967721
|
|
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 36X70 10DEG LONGEVITY 6305-70-36
|
Facility
|
IP
|
$9,973.00
|
|
| Hospital Charge Code |
2967755
|
|
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 36X70 10DEG LONGEVITY 6305-70-36
|
Facility
|
OP
|
$9,973.00
|
|
| Hospital Charge Code |
2967755
|
|
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 47/48/49 BIPOLAR CUP 00-5001-047-28
|
Facility
|
IP
|
$3,104.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2967725
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,520.96 |
| Max. Negotiated Rate |
$2,855.68 |
| Rate for Payer: Aetna Commercial |
$2,793.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,669.44
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,645.12
|
| Rate for Payer: Cash Price |
$931.20
|
| Rate for Payer: Cigna Commercial |
$2,855.68
|
| Rate for Payer: Health EOS Commercial |
$2,762.56
|
| Rate for Payer: HFN Commercial |
$2,855.68
|
| Rate for Payer: Multiplan Commercial |
$2,483.20
|
| Rate for Payer: NAPHCARE Commercial |
$1,862.40
|
| Rate for Payer: Preferred Network Access Commercial |
$2,855.68
|
| Rate for Payer: Quartz Beloit One Network |
$1,520.96
|
| Rate for Payer: Quartz Commercial |
$1,862.40
|
| Rate for Payer: WEA Trust Commercial |
$1,707.20
|
| Rate for Payer: WPS Commercial |
$2,299.13
|
|
|
LINER 47/48/49 BIPOLAR CUP 00-5001-047-28
|
Facility
|
OP
|
$3,104.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2967725
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$869.12 |
| Max. Negotiated Rate |
$12,416.00 |
| Rate for Payer: Aetna Commercial |
$2,793.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,669.44
|
| Rate for Payer: Aetna Managed Medicare |
$869.12
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,017.60
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,552.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,489.92
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,645.12
|
| Rate for Payer: Cash Price |
$931.20
|
| Rate for Payer: Cigna Commercial |
$2,855.68
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,737.00
|
| Rate for Payer: Health EOS Commercial |
$2,762.56
|
| Rate for Payer: HFN Commercial |
$2,855.68
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,328.00
|
| Rate for Payer: Multiplan Commercial |
$2,483.20
|
| Rate for Payer: NAPHCARE Commercial |
$1,862.40
|
| Rate for Payer: Preferred Network Access Commercial |
$2,855.68
|
| Rate for Payer: Quartz Beloit One Network |
$1,520.96
|
| Rate for Payer: Quartz Commercial |
$2,017.60
|
| Rate for Payer: Quartz Medicare Advantage |
$1,862.40
|
| Rate for Payer: The Alliance Commercial |
$12,416.00
|
| Rate for Payer: WEA Trust Commercial |
$1,707.20
|
| Rate for Payer: WPS Commercial |
$2,299.13
|
|
|
LINER 48X28 LONGEV. 6310-48-28
|
Facility
|
IP
|
$8,851.00
|
|
| Hospital Charge Code |
2967726
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,336.99 |
| Max. Negotiated Rate |
$8,142.92 |
| Rate for Payer: Aetna Commercial |
$7,965.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,611.86
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,691.03
|
| Rate for Payer: Cash Price |
$2,655.30
|
| Rate for Payer: Cigna Commercial |
$8,142.92
|
| Rate for Payer: Health EOS Commercial |
$7,877.39
|
| Rate for Payer: HFN Commercial |
$8,142.92
|
| Rate for Payer: Multiplan Commercial |
$7,080.80
|
| Rate for Payer: NAPHCARE Commercial |
$5,310.60
|
| Rate for Payer: Preferred Network Access Commercial |
$8,142.92
|
| Rate for Payer: Quartz Beloit One Network |
$4,336.99
|
| Rate for Payer: Quartz Commercial |
$5,310.60
|
| Rate for Payer: WEA Trust Commercial |
$4,868.05
|
| Rate for Payer: WPS Commercial |
$6,555.94
|
|
|
LINER 48X28 LONGEV. 6310-48-28
|
Facility
|
OP
|
$8,851.00
|
|
| Hospital Charge Code |
2967726
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,478.28 |
| Max. Negotiated Rate |
$35,404.00 |
| Rate for Payer: Aetna Commercial |
$7,965.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,611.86
|
| Rate for Payer: Aetna Managed Medicare |
$2,478.28
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5,753.15
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,425.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,248.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,691.03
|
| Rate for Payer: Cash Price |
$2,655.30
|
| Rate for Payer: Cigna Commercial |
$8,142.92
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,953.02
|
| Rate for Payer: Health EOS Commercial |
$7,877.39
|
| Rate for Payer: HFN Commercial |
$8,142.92
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$6,638.25
|
| Rate for Payer: Multiplan Commercial |
$7,080.80
|
| Rate for Payer: NAPHCARE Commercial |
$5,310.60
|
| Rate for Payer: Preferred Network Access Commercial |
$8,142.92
|
| Rate for Payer: Quartz Beloit One Network |
$4,336.99
|
| Rate for Payer: Quartz Commercial |
$5,753.15
|
| Rate for Payer: Quartz Medicare Advantage |
$5,310.60
|
| Rate for Payer: The Alliance Commercial |
$35,404.00
|
| Rate for Payer: WEA Trust Commercial |
$4,868.05
|
| Rate for Payer: WPS Commercial |
$6,555.94
|
|
|
LINER 48X32 LONGEVITY 10 DEG 6310-48-32
|
Facility
|
IP
|
$1,212.00
|
|
| Hospital Charge Code |
2967728
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$593.88 |
| Max. Negotiated Rate |
$1,115.04 |
| Rate for Payer: Aetna Commercial |
$1,090.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,042.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$642.36
|
| Rate for Payer: Cash Price |
$363.60
|
| Rate for Payer: Cigna Commercial |
$1,115.04
|
| Rate for Payer: Health EOS Commercial |
$1,078.68
|
| Rate for Payer: HFN Commercial |
$1,115.04
|
| Rate for Payer: Multiplan Commercial |
$969.60
|
| Rate for Payer: NAPHCARE Commercial |
$727.20
|
| Rate for Payer: Preferred Network Access Commercial |
$1,115.04
|
| Rate for Payer: Quartz Beloit One Network |
$593.88
|
| Rate for Payer: Quartz Commercial |
$727.20
|
| Rate for Payer: WEA Trust Commercial |
$666.60
|
| Rate for Payer: WPS Commercial |
$897.73
|
|
|
LINER 48X32 LONGEVITY 10 DEG 6310-48-32
|
Facility
|
OP
|
$1,212.00
|
|
| Hospital Charge Code |
2967728
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$339.36 |
| Max. Negotiated Rate |
$4,848.00 |
| Rate for Payer: Aetna Commercial |
$1,090.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,042.32
|
| Rate for Payer: Aetna Managed Medicare |
$339.36
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$787.80
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$606.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$581.76
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$642.36
|
| Rate for Payer: Cash Price |
$363.60
|
| Rate for Payer: Cigna Commercial |
$1,115.04
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$678.24
|
| Rate for Payer: Health EOS Commercial |
$1,078.68
|
| Rate for Payer: HFN Commercial |
$1,115.04
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$909.00
|
| Rate for Payer: Multiplan Commercial |
$969.60
|
| Rate for Payer: NAPHCARE Commercial |
$727.20
|
| Rate for Payer: Preferred Network Access Commercial |
$1,115.04
|
| Rate for Payer: Quartz Beloit One Network |
$593.88
|
| Rate for Payer: Quartz Commercial |
$787.80
|
| Rate for Payer: Quartz Medicare Advantage |
$727.20
|
| Rate for Payer: The Alliance Commercial |
$4,848.00
|
| Rate for Payer: WEA Trust Commercial |
$666.60
|
| Rate for Payer: WPS Commercial |
$897.73
|
|
|
LINER 50/51/52 BIPOLAR CUP 5001-50-28
|
Facility
|
IP
|
$3,104.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2967729
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,520.96 |
| Max. Negotiated Rate |
$2,855.68 |
| Rate for Payer: Aetna Commercial |
$2,793.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,669.44
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,645.12
|
| Rate for Payer: Cash Price |
$931.20
|
| Rate for Payer: Cigna Commercial |
$2,855.68
|
| Rate for Payer: Health EOS Commercial |
$2,762.56
|
| Rate for Payer: HFN Commercial |
$2,855.68
|
| Rate for Payer: Multiplan Commercial |
$2,483.20
|
| Rate for Payer: NAPHCARE Commercial |
$1,862.40
|
| Rate for Payer: Preferred Network Access Commercial |
$2,855.68
|
| Rate for Payer: Quartz Beloit One Network |
$1,520.96
|
| Rate for Payer: Quartz Commercial |
$1,862.40
|
| Rate for Payer: WEA Trust Commercial |
$1,707.20
|
| Rate for Payer: WPS Commercial |
$2,299.13
|
|
|
LINER 50/51/52 BIPOLAR CUP 5001-50-28
|
Facility
|
OP
|
$3,104.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2967729
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$869.12 |
| Max. Negotiated Rate |
$12,416.00 |
| Rate for Payer: Aetna Commercial |
$2,793.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,669.44
|
| Rate for Payer: Aetna Managed Medicare |
$869.12
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,017.60
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,552.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,489.92
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,645.12
|
| Rate for Payer: Cash Price |
$931.20
|
| Rate for Payer: Cigna Commercial |
$2,855.68
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,737.00
|
| Rate for Payer: Health EOS Commercial |
$2,762.56
|
| Rate for Payer: HFN Commercial |
$2,855.68
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,328.00
|
| Rate for Payer: Multiplan Commercial |
$2,483.20
|
| Rate for Payer: NAPHCARE Commercial |
$1,862.40
|
| Rate for Payer: Preferred Network Access Commercial |
$2,855.68
|
| Rate for Payer: Quartz Beloit One Network |
$1,520.96
|
| Rate for Payer: Quartz Commercial |
$2,017.60
|
| Rate for Payer: Quartz Medicare Advantage |
$1,862.40
|
| Rate for Payer: The Alliance Commercial |
$12,416.00
|
| Rate for Payer: WEA Trust Commercial |
$1,707.20
|
| Rate for Payer: WPS Commercial |
$2,299.13
|
|
|
LINER 50 X 32 CONTINUUM ELEV 00-8752-009-32
|
Facility
|
OP
|
$8,851.00
|
|
| Hospital Charge Code |
2967730
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,478.28 |
| Max. Negotiated Rate |
$35,404.00 |
| Rate for Payer: Aetna Commercial |
$7,965.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,611.86
|
| Rate for Payer: Aetna Managed Medicare |
$2,478.28
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5,753.15
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,425.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,248.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,691.03
|
| Rate for Payer: Cash Price |
$2,655.30
|
| Rate for Payer: Cigna Commercial |
$8,142.92
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,953.02
|
| Rate for Payer: Health EOS Commercial |
$7,877.39
|
| Rate for Payer: HFN Commercial |
$8,142.92
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$6,638.25
|
| Rate for Payer: Multiplan Commercial |
$7,080.80
|
| Rate for Payer: NAPHCARE Commercial |
$5,310.60
|
| Rate for Payer: Preferred Network Access Commercial |
$8,142.92
|
| Rate for Payer: Quartz Beloit One Network |
$4,336.99
|
| Rate for Payer: Quartz Commercial |
$5,753.15
|
| Rate for Payer: Quartz Medicare Advantage |
$5,310.60
|
| Rate for Payer: The Alliance Commercial |
$35,404.00
|
| Rate for Payer: WEA Trust Commercial |
$4,868.05
|
| Rate for Payer: WPS Commercial |
$6,555.94
|
|
|
LINER 50 X 32 CONTINUUM ELEV 00-8752-009-32
|
Facility
|
IP
|
$8,851.00
|
|
| Hospital Charge Code |
2967730
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,336.99 |
| Max. Negotiated Rate |
$8,142.92 |
| Rate for Payer: Aetna Commercial |
$7,965.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,611.86
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,691.03
|
| Rate for Payer: Cash Price |
$2,655.30
|
| Rate for Payer: Cigna Commercial |
$8,142.92
|
| Rate for Payer: Health EOS Commercial |
$7,877.39
|
| Rate for Payer: HFN Commercial |
$8,142.92
|
| Rate for Payer: Multiplan Commercial |
$7,080.80
|
| Rate for Payer: NAPHCARE Commercial |
$5,310.60
|
| Rate for Payer: Preferred Network Access Commercial |
$8,142.92
|
| Rate for Payer: Quartz Beloit One Network |
$4,336.99
|
| Rate for Payer: Quartz Commercial |
$5,310.60
|
| Rate for Payer: WEA Trust Commercial |
$4,868.05
|
| Rate for Payer: WPS Commercial |
$6,555.94
|
|
|
LINER 50X32 LONGEVITY 10 DEG 6310-50-32
|
Facility
|
OP
|
$1,212.00
|
|
| Hospital Charge Code |
2967731
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$339.36 |
| Max. Negotiated Rate |
$4,848.00 |
| Rate for Payer: Aetna Commercial |
$1,090.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,042.32
|
| Rate for Payer: Aetna Managed Medicare |
$339.36
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$787.80
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$606.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$581.76
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$642.36
|
| Rate for Payer: Cash Price |
$363.60
|
| Rate for Payer: Cigna Commercial |
$1,115.04
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$678.24
|
| Rate for Payer: Health EOS Commercial |
$1,078.68
|
| Rate for Payer: HFN Commercial |
$1,115.04
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$909.00
|
| Rate for Payer: Multiplan Commercial |
$969.60
|
| Rate for Payer: NAPHCARE Commercial |
$727.20
|
| Rate for Payer: Preferred Network Access Commercial |
$1,115.04
|
| Rate for Payer: Quartz Beloit One Network |
$593.88
|
| Rate for Payer: Quartz Commercial |
$787.80
|
| Rate for Payer: Quartz Medicare Advantage |
$727.20
|
| Rate for Payer: The Alliance Commercial |
$4,848.00
|
| Rate for Payer: WEA Trust Commercial |
$666.60
|
| Rate for Payer: WPS Commercial |
$897.73
|
|
|
LINER 50X32 LONGEVITY 10 DEG 6310-50-32
|
Facility
|
IP
|
$1,212.00
|
|
| Hospital Charge Code |
2967731
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$593.88 |
| Max. Negotiated Rate |
$1,115.04 |
| Rate for Payer: Aetna Commercial |
$1,090.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,042.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$642.36
|
| Rate for Payer: Cash Price |
$363.60
|
| Rate for Payer: Cigna Commercial |
$1,115.04
|
| Rate for Payer: Health EOS Commercial |
$1,078.68
|
| Rate for Payer: HFN Commercial |
$1,115.04
|
| Rate for Payer: Multiplan Commercial |
$969.60
|
| Rate for Payer: NAPHCARE Commercial |
$727.20
|
| Rate for Payer: Preferred Network Access Commercial |
$1,115.04
|
| Rate for Payer: Quartz Beloit One Network |
$593.88
|
| Rate for Payer: Quartz Commercial |
$727.20
|
| Rate for Payer: WEA Trust Commercial |
$666.60
|
| Rate for Payer: WPS Commercial |
$897.73
|
|
|
LINER 52 X 32 CONTINUUM ELEV 00-8752-010-32
|
Facility
|
IP
|
$9,192.00
|
|
| Hospital Charge Code |
2967732
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,504.08 |
| Max. Negotiated Rate |
$8,456.64 |
| Rate for Payer: Aetna Commercial |
$8,272.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,905.12
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,871.76
|
| Rate for Payer: Cash Price |
$2,757.60
|
| Rate for Payer: Cigna Commercial |
$8,456.64
|
| Rate for Payer: Health EOS Commercial |
$8,180.88
|
| Rate for Payer: HFN Commercial |
$8,456.64
|
| Rate for Payer: Multiplan Commercial |
$7,353.60
|
| Rate for Payer: NAPHCARE Commercial |
$5,515.20
|
| Rate for Payer: Preferred Network Access Commercial |
$8,456.64
|
| Rate for Payer: Quartz Beloit One Network |
$4,504.08
|
| Rate for Payer: Quartz Commercial |
$5,515.20
|
| Rate for Payer: WEA Trust Commercial |
$5,055.60
|
| Rate for Payer: WPS Commercial |
$6,808.51
|
|
