|
LINER 52 X 32 CONTINUUM ELEV 00-8752-010-32
|
Facility
|
OP
|
$9,192.00
|
|
| Hospital Charge Code |
2967732
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,573.76 |
| Max. Negotiated Rate |
$36,768.00 |
| Rate for Payer: Aetna Commercial |
$8,272.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,905.12
|
| Rate for Payer: Aetna Managed Medicare |
$2,573.76
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5,974.80
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,596.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,412.16
|
| 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: Dean Health DHI/DHP/ASO |
$5,143.84
|
| Rate for Payer: Health EOS Commercial |
$8,180.88
|
| Rate for Payer: HFN Commercial |
$8,456.64
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$6,894.00
|
| 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 |
$5,974.80
|
| Rate for Payer: Quartz Medicare Advantage |
$5,515.20
|
| Rate for Payer: The Alliance Commercial |
$36,768.00
|
| Rate for Payer: WEA Trust Commercial |
$5,055.60
|
| Rate for Payer: WPS Commercial |
$6,808.51
|
|
|
LINER 52 X 36 CONTINUUM ELEV 00-8752-010-36
|
Facility
|
IP
|
$10,355.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2967733
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,073.95 |
| Max. Negotiated Rate |
$9,526.60 |
| Rate for Payer: Aetna Commercial |
$9,319.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$8,905.30
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,488.15
|
| Rate for Payer: Cash Price |
$3,106.50
|
| Rate for Payer: Cigna Commercial |
$9,526.60
|
| Rate for Payer: Health EOS Commercial |
$9,215.95
|
| Rate for Payer: HFN Commercial |
$9,526.60
|
| Rate for Payer: Multiplan Commercial |
$8,284.00
|
| Rate for Payer: NAPHCARE Commercial |
$6,213.00
|
| Rate for Payer: Preferred Network Access Commercial |
$9,526.60
|
| Rate for Payer: Quartz Beloit One Network |
$5,073.95
|
| Rate for Payer: Quartz Commercial |
$6,213.00
|
| Rate for Payer: WEA Trust Commercial |
$5,695.25
|
| Rate for Payer: WPS Commercial |
$7,669.95
|
|
|
LINER 52 X 36 CONTINUUM ELEV 00-8752-010-36
|
Facility
|
OP
|
$10,355.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2967733
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,899.40 |
| Max. Negotiated Rate |
$41,420.00 |
| Rate for Payer: Aetna Commercial |
$9,319.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$8,905.30
|
| Rate for Payer: Aetna Managed Medicare |
$2,899.40
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$6,730.75
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$5,177.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,970.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,488.15
|
| Rate for Payer: Cash Price |
$3,106.50
|
| Rate for Payer: Cigna Commercial |
$9,526.60
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$5,794.66
|
| Rate for Payer: Health EOS Commercial |
$9,215.95
|
| Rate for Payer: HFN Commercial |
$9,526.60
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$7,766.25
|
| Rate for Payer: Multiplan Commercial |
$8,284.00
|
| Rate for Payer: NAPHCARE Commercial |
$6,213.00
|
| Rate for Payer: Preferred Network Access Commercial |
$9,526.60
|
| Rate for Payer: Quartz Beloit One Network |
$5,073.95
|
| Rate for Payer: Quartz Commercial |
$6,730.75
|
| Rate for Payer: Quartz Medicare Advantage |
$6,213.00
|
| Rate for Payer: The Alliance Commercial |
$41,420.00
|
| Rate for Payer: WEA Trust Commercial |
$5,695.25
|
| Rate for Payer: WPS Commercial |
$7,669.95
|
|
|
LINER 53/54/55 BIPOLAR CUP 5001-053-28
|
Facility
|
OP
|
$2,990.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2967734
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$837.20 |
| Max. Negotiated Rate |
$11,960.00 |
| Rate for Payer: Aetna Commercial |
$2,691.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,571.40
|
| Rate for Payer: Aetna Managed Medicare |
$837.20
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,943.50
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,495.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,435.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,584.70
|
| Rate for Payer: Cash Price |
$897.00
|
| Rate for Payer: Cigna Commercial |
$2,750.80
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,673.20
|
| Rate for Payer: Health EOS Commercial |
$2,661.10
|
| Rate for Payer: HFN Commercial |
$2,750.80
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,242.50
|
| Rate for Payer: Multiplan Commercial |
$2,392.00
|
| Rate for Payer: NAPHCARE Commercial |
$1,794.00
|
| Rate for Payer: Preferred Network Access Commercial |
$2,750.80
|
| Rate for Payer: Quartz Beloit One Network |
$1,465.10
|
| Rate for Payer: Quartz Commercial |
$1,943.50
|
| Rate for Payer: Quartz Medicare Advantage |
$1,794.00
|
| Rate for Payer: The Alliance Commercial |
$11,960.00
|
| Rate for Payer: WEA Trust Commercial |
$1,644.50
|
| Rate for Payer: WPS Commercial |
$2,214.69
|
|
|
LINER 53/54/55 BIPOLAR CUP 5001-053-28
|
Facility
|
IP
|
$2,990.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2967734
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,465.10 |
| Max. Negotiated Rate |
$2,750.80 |
| Rate for Payer: Aetna Commercial |
$2,691.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,571.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,584.70
|
| Rate for Payer: Cash Price |
$897.00
|
| Rate for Payer: Cigna Commercial |
$2,750.80
|
| Rate for Payer: Health EOS Commercial |
$2,661.10
|
| Rate for Payer: HFN Commercial |
$2,750.80
|
| Rate for Payer: Multiplan Commercial |
$2,392.00
|
| Rate for Payer: NAPHCARE Commercial |
$1,794.00
|
| Rate for Payer: Preferred Network Access Commercial |
$2,750.80
|
| Rate for Payer: Quartz Beloit One Network |
$1,465.10
|
| Rate for Payer: Quartz Commercial |
$1,794.00
|
| Rate for Payer: WEA Trust Commercial |
$1,644.50
|
| Rate for Payer: WPS Commercial |
$2,214.69
|
|
|
LINER 54 X 32 CONTINUUM ELEV 00-8752-11-32
|
Facility
|
OP
|
$8,851.00
|
|
| Hospital Charge Code |
2967735
|
|
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 54 X 32 CONTINUUM ELEV 00-8752-11-32
|
Facility
|
IP
|
$8,851.00
|
|
| Hospital Charge Code |
2967735
|
|
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 54 X 36 CONTINUUM ELEV 00-8752-011-36
|
Facility
|
IP
|
$10,355.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2967736
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,073.95 |
| Max. Negotiated Rate |
$9,526.60 |
| Rate for Payer: Aetna Commercial |
$9,319.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$8,905.30
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,488.15
|
| Rate for Payer: Cash Price |
$3,106.50
|
| Rate for Payer: Cigna Commercial |
$9,526.60
|
| Rate for Payer: Health EOS Commercial |
$9,215.95
|
| Rate for Payer: HFN Commercial |
$9,526.60
|
| Rate for Payer: Multiplan Commercial |
$8,284.00
|
| Rate for Payer: NAPHCARE Commercial |
$6,213.00
|
| Rate for Payer: Preferred Network Access Commercial |
$9,526.60
|
| Rate for Payer: Quartz Beloit One Network |
$5,073.95
|
| Rate for Payer: Quartz Commercial |
$6,213.00
|
| Rate for Payer: WEA Trust Commercial |
$5,695.25
|
| Rate for Payer: WPS Commercial |
$7,669.95
|
|
|
LINER 54 X 36 CONTINUUM ELEV 00-8752-011-36
|
Facility
|
OP
|
$10,355.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2967736
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,899.40 |
| Max. Negotiated Rate |
$41,420.00 |
| Rate for Payer: Aetna Commercial |
$9,319.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$8,905.30
|
| Rate for Payer: Aetna Managed Medicare |
$2,899.40
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$6,730.75
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$5,177.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,970.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,488.15
|
| Rate for Payer: Cash Price |
$3,106.50
|
| Rate for Payer: Cigna Commercial |
$9,526.60
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$5,794.66
|
| Rate for Payer: Health EOS Commercial |
$9,215.95
|
| Rate for Payer: HFN Commercial |
$9,526.60
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$7,766.25
|
| Rate for Payer: Multiplan Commercial |
$8,284.00
|
| Rate for Payer: NAPHCARE Commercial |
$6,213.00
|
| Rate for Payer: Preferred Network Access Commercial |
$9,526.60
|
| Rate for Payer: Quartz Beloit One Network |
$5,073.95
|
| Rate for Payer: Quartz Commercial |
$6,730.75
|
| Rate for Payer: Quartz Medicare Advantage |
$6,213.00
|
| Rate for Payer: The Alliance Commercial |
$41,420.00
|
| Rate for Payer: WEA Trust Commercial |
$5,695.25
|
| Rate for Payer: WPS Commercial |
$7,669.95
|
|
|
LINER 56 X 32 CONTINUUM ELEV 00-8752-012-32
|
Facility
|
OP
|
$8,851.00
|
|
| Hospital Charge Code |
2967737
|
|
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 56 X 32 CONTINUUM ELEV 00-8752-012-32
|
Facility
|
IP
|
$8,851.00
|
|
| Hospital Charge Code |
2967737
|
|
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 56X32 LONGEVITY 10 DEG 6310-56-32
|
Facility
|
IP
|
$1,212.00
|
|
| Hospital Charge Code |
2967738
|
|
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 56X32 LONGEVITY 10 DEG 6310-56-32
|
Facility
|
OP
|
$1,212.00
|
|
| Hospital Charge Code |
2967738
|
|
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 57/58 BIPOLAR CUP 5001-57-28
|
Facility
|
OP
|
$2,990.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2967740
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$837.20 |
| Max. Negotiated Rate |
$11,960.00 |
| Rate for Payer: Aetna Commercial |
$2,691.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,571.40
|
| Rate for Payer: Aetna Managed Medicare |
$837.20
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,943.50
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,495.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,435.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,584.70
|
| Rate for Payer: Cash Price |
$897.00
|
| Rate for Payer: Cigna Commercial |
$2,750.80
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,673.20
|
| Rate for Payer: Health EOS Commercial |
$2,661.10
|
| Rate for Payer: HFN Commercial |
$2,750.80
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,242.50
|
| Rate for Payer: Multiplan Commercial |
$2,392.00
|
| Rate for Payer: NAPHCARE Commercial |
$1,794.00
|
| Rate for Payer: Preferred Network Access Commercial |
$2,750.80
|
| Rate for Payer: Quartz Beloit One Network |
$1,465.10
|
| Rate for Payer: Quartz Commercial |
$1,943.50
|
| Rate for Payer: Quartz Medicare Advantage |
$1,794.00
|
| Rate for Payer: The Alliance Commercial |
$11,960.00
|
| Rate for Payer: WEA Trust Commercial |
$1,644.50
|
| Rate for Payer: WPS Commercial |
$2,214.69
|
|
|
LINER 57/58 BIPOLAR CUP 5001-57-28
|
Facility
|
IP
|
$2,990.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2967740
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,465.10 |
| Max. Negotiated Rate |
$2,750.80 |
| Rate for Payer: Aetna Commercial |
$2,691.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,571.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,584.70
|
| Rate for Payer: Cash Price |
$897.00
|
| Rate for Payer: Cigna Commercial |
$2,750.80
|
| Rate for Payer: Health EOS Commercial |
$2,661.10
|
| Rate for Payer: HFN Commercial |
$2,750.80
|
| Rate for Payer: Multiplan Commercial |
$2,392.00
|
| Rate for Payer: NAPHCARE Commercial |
$1,794.00
|
| Rate for Payer: Preferred Network Access Commercial |
$2,750.80
|
| Rate for Payer: Quartz Beloit One Network |
$1,465.10
|
| Rate for Payer: Quartz Commercial |
$1,794.00
|
| Rate for Payer: WEA Trust Commercial |
$1,644.50
|
| Rate for Payer: WPS Commercial |
$2,214.69
|
|
|
LINER 58X32 10DEG 6310-58-32
|
Facility
|
OP
|
$1,212.00
|
|
| Hospital Charge Code |
2967550
|
|
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 58X32 10DEG 6310-58-32
|
Facility
|
IP
|
$1,212.00
|
|
| Hospital Charge Code |
2967550
|
|
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 58 X 32 CONTINUUM ELEV 00-8752-013-32
|
Facility
|
IP
|
$8,851.00
|
|
| Hospital Charge Code |
2967741
|
|
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 58 X 32 CONTINUUM ELEV 00-8752-013-32
|
Facility
|
OP
|
$8,851.00
|
|
| Hospital Charge Code |
2967741
|
|
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 60/62 BIPOLAR CUP 5001-60-28
|
Facility
|
OP
|
$2,990.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2967743
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$837.20 |
| Max. Negotiated Rate |
$11,960.00 |
| Rate for Payer: Aetna Commercial |
$2,691.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,571.40
|
| Rate for Payer: Aetna Managed Medicare |
$837.20
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,943.50
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,495.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,435.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,584.70
|
| Rate for Payer: Cash Price |
$897.00
|
| Rate for Payer: Cigna Commercial |
$2,750.80
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,673.20
|
| Rate for Payer: Health EOS Commercial |
$2,661.10
|
| Rate for Payer: HFN Commercial |
$2,750.80
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,242.50
|
| Rate for Payer: Multiplan Commercial |
$2,392.00
|
| Rate for Payer: NAPHCARE Commercial |
$1,794.00
|
| Rate for Payer: Preferred Network Access Commercial |
$2,750.80
|
| Rate for Payer: Quartz Beloit One Network |
$1,465.10
|
| Rate for Payer: Quartz Commercial |
$1,943.50
|
| Rate for Payer: Quartz Medicare Advantage |
$1,794.00
|
| Rate for Payer: The Alliance Commercial |
$11,960.00
|
| Rate for Payer: WEA Trust Commercial |
$1,644.50
|
| Rate for Payer: WPS Commercial |
$2,214.69
|
|
|
LINER 60/62 BIPOLAR CUP 5001-60-28
|
Facility
|
IP
|
$2,990.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2967743
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,465.10 |
| Max. Negotiated Rate |
$2,750.80 |
| Rate for Payer: Aetna Commercial |
$2,691.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,571.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,584.70
|
| Rate for Payer: Cash Price |
$897.00
|
| Rate for Payer: Cigna Commercial |
$2,750.80
|
| Rate for Payer: Health EOS Commercial |
$2,661.10
|
| Rate for Payer: HFN Commercial |
$2,750.80
|
| Rate for Payer: Multiplan Commercial |
$2,392.00
|
| Rate for Payer: NAPHCARE Commercial |
$1,794.00
|
| Rate for Payer: Preferred Network Access Commercial |
$2,750.80
|
| Rate for Payer: Quartz Beloit One Network |
$1,465.10
|
| Rate for Payer: Quartz Commercial |
$1,794.00
|
| Rate for Payer: WEA Trust Commercial |
$1,644.50
|
| Rate for Payer: WPS Commercial |
$2,214.69
|
|
|
LINER 60X32 10DEG 6310-60-32
|
Facility
|
IP
|
$1,212.00
|
|
| Hospital Charge Code |
2967551
|
|
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 60X32 10DEG 6310-60-32
|
Facility
|
OP
|
$1,212.00
|
|
| Hospital Charge Code |
2967551
|
|
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 60 X 32 CONTINUUM ELEV 00-8752-014-32
|
Facility
|
IP
|
$8,851.00
|
|
| Hospital Charge Code |
2967744
|
|
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 60 X 32 CONTINUUM ELEV 00-8752-014-32
|
Facility
|
OP
|
$8,851.00
|
|
| Hospital Charge Code |
2967744
|
|
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
|
|
