|
LINER CONTINUUM LONGEVITY 7MM OFFSET 36MM X 58MM 00-8754-013-36
|
Facility
|
IP
|
$8,826.00
|
|
| Hospital Charge Code |
3825394
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,324.74 |
| Max. Negotiated Rate |
$8,119.92 |
| Rate for Payer: Aetna Commercial |
$7,943.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,590.36
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,677.78
|
| Rate for Payer: Cash Price |
$2,647.80
|
| Rate for Payer: Cigna Commercial |
$8,119.92
|
| Rate for Payer: Health EOS Commercial |
$7,855.14
|
| Rate for Payer: HFN Commercial |
$8,119.92
|
| Rate for Payer: Multiplan Commercial |
$7,060.80
|
| Rate for Payer: NAPHCARE Commercial |
$5,295.60
|
| Rate for Payer: Preferred Network Access Commercial |
$8,119.92
|
| Rate for Payer: Quartz Beloit One Network |
$4,324.74
|
| Rate for Payer: Quartz Commercial |
$5,295.60
|
| Rate for Payer: WEA Trust Commercial |
$4,854.30
|
| Rate for Payer: WPS Commercial |
$6,537.42
|
|
|
LINER CONTINUUM VE 32MM GG ELEV RIM 00-8852-008-32
|
Facility
|
OP
|
$10,575.00
|
|
| Hospital Charge Code |
4640898
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,961.00 |
| Max. Negotiated Rate |
$42,300.00 |
| Rate for Payer: Aetna Commercial |
$9,517.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$9,094.50
|
| Rate for Payer: Aetna Managed Medicare |
$2,961.00
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$6,873.75
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$5,287.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$5,076.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,604.75
|
| Rate for Payer: Cash Price |
$3,172.50
|
| Rate for Payer: Cigna Commercial |
$9,729.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$5,917.77
|
| Rate for Payer: Health EOS Commercial |
$9,411.75
|
| Rate for Payer: HFN Commercial |
$9,729.00
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$7,931.25
|
| Rate for Payer: Multiplan Commercial |
$8,460.00
|
| Rate for Payer: NAPHCARE Commercial |
$6,345.00
|
| Rate for Payer: Preferred Network Access Commercial |
$9,729.00
|
| Rate for Payer: Quartz Beloit One Network |
$5,181.75
|
| Rate for Payer: Quartz Commercial |
$6,873.75
|
| Rate for Payer: Quartz Medicare Advantage |
$6,345.00
|
| Rate for Payer: The Alliance Commercial |
$42,300.00
|
| Rate for Payer: WEA Trust Commercial |
$5,816.25
|
| Rate for Payer: WPS Commercial |
$7,832.90
|
|
|
LINER CONTINUUM VE 32MM GG ELEV RIM 00-8852-008-32
|
Facility
|
IP
|
$10,575.00
|
|
| Hospital Charge Code |
4640898
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,181.75 |
| Max. Negotiated Rate |
$9,729.00 |
| Rate for Payer: Aetna Commercial |
$9,517.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$9,094.50
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,604.75
|
| Rate for Payer: Cash Price |
$3,172.50
|
| Rate for Payer: Cigna Commercial |
$9,729.00
|
| Rate for Payer: Health EOS Commercial |
$9,411.75
|
| Rate for Payer: HFN Commercial |
$9,729.00
|
| Rate for Payer: Multiplan Commercial |
$8,460.00
|
| Rate for Payer: NAPHCARE Commercial |
$6,345.00
|
| Rate for Payer: Preferred Network Access Commercial |
$9,729.00
|
| Rate for Payer: Quartz Beloit One Network |
$5,181.75
|
| Rate for Payer: Quartz Commercial |
$6,345.00
|
| Rate for Payer: WEA Trust Commercial |
$5,816.25
|
| Rate for Payer: WPS Commercial |
$7,832.90
|
|
|
LINER CONTINUUM VE ELEVATED HH 32MM 00-8852-009-32
|
Facility
|
IP
|
$10,185.00
|
|
| Hospital Charge Code |
4520252
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,990.65 |
| Max. Negotiated Rate |
$9,370.20 |
| Rate for Payer: Aetna Commercial |
$9,166.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$8,759.10
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,398.05
|
| Rate for Payer: Cash Price |
$3,055.50
|
| Rate for Payer: Cigna Commercial |
$9,370.20
|
| Rate for Payer: Health EOS Commercial |
$9,064.65
|
| Rate for Payer: HFN Commercial |
$9,370.20
|
| Rate for Payer: Multiplan Commercial |
$8,148.00
|
| Rate for Payer: NAPHCARE Commercial |
$6,111.00
|
| Rate for Payer: Preferred Network Access Commercial |
$9,370.20
|
| Rate for Payer: Quartz Beloit One Network |
$4,990.65
|
| Rate for Payer: Quartz Commercial |
$6,111.00
|
| Rate for Payer: WEA Trust Commercial |
$5,601.75
|
| Rate for Payer: WPS Commercial |
$7,544.03
|
|
|
LINER CONTINUUM VE ELEVATED HH 32MM 00-8852-009-32
|
Facility
|
OP
|
$10,185.00
|
|
| Hospital Charge Code |
4520252
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,851.80 |
| Max. Negotiated Rate |
$40,740.00 |
| Rate for Payer: Aetna Commercial |
$9,166.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$8,759.10
|
| Rate for Payer: Aetna Managed Medicare |
$2,851.80
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$6,620.25
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$5,092.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,888.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,398.05
|
| Rate for Payer: Cash Price |
$3,055.50
|
| Rate for Payer: Cigna Commercial |
$9,370.20
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$5,699.53
|
| Rate for Payer: Health EOS Commercial |
$9,064.65
|
| Rate for Payer: HFN Commercial |
$9,370.20
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$7,638.75
|
| Rate for Payer: Multiplan Commercial |
$8,148.00
|
| Rate for Payer: NAPHCARE Commercial |
$6,111.00
|
| Rate for Payer: Preferred Network Access Commercial |
$9,370.20
|
| Rate for Payer: Quartz Beloit One Network |
$4,990.65
|
| Rate for Payer: Quartz Commercial |
$6,620.25
|
| Rate for Payer: Quartz Medicare Advantage |
$6,111.00
|
| Rate for Payer: The Alliance Commercial |
$40,740.00
|
| Rate for Payer: WEA Trust Commercial |
$5,601.75
|
| Rate for Payer: WPS Commercial |
$7,544.03
|
|
|
LINER CONTINUUM VE ELEVATED II 36MM 00-8852-010-36
|
Facility
|
OP
|
$10,576.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
3279474
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,961.28 |
| Max. Negotiated Rate |
$42,304.00 |
| Rate for Payer: Aetna Commercial |
$9,518.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$9,095.36
|
| Rate for Payer: Aetna Managed Medicare |
$2,961.28
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$6,874.40
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$5,288.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$5,076.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,605.28
|
| Rate for Payer: Cash Price |
$3,172.80
|
| Rate for Payer: Cigna Commercial |
$9,729.92
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$5,918.33
|
| Rate for Payer: Health EOS Commercial |
$9,412.64
|
| Rate for Payer: HFN Commercial |
$9,729.92
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$7,932.00
|
| Rate for Payer: Multiplan Commercial |
$8,460.80
|
| Rate for Payer: NAPHCARE Commercial |
$6,345.60
|
| Rate for Payer: Preferred Network Access Commercial |
$9,729.92
|
| Rate for Payer: Quartz Beloit One Network |
$5,182.24
|
| Rate for Payer: Quartz Commercial |
$6,874.40
|
| Rate for Payer: Quartz Medicare Advantage |
$6,345.60
|
| Rate for Payer: The Alliance Commercial |
$42,304.00
|
| Rate for Payer: WEA Trust Commercial |
$5,816.80
|
| Rate for Payer: WPS Commercial |
$7,833.64
|
|
|
LINER CONTINUUM VE ELEVATED II 36MM 00-8852-010-36
|
Facility
|
IP
|
$10,576.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
3279474
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,182.24 |
| Max. Negotiated Rate |
$9,729.92 |
| Rate for Payer: Aetna Commercial |
$9,518.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$9,095.36
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,605.28
|
| Rate for Payer: Cash Price |
$3,172.80
|
| Rate for Payer: Cigna Commercial |
$9,729.92
|
| Rate for Payer: Health EOS Commercial |
$9,412.64
|
| Rate for Payer: HFN Commercial |
$9,729.92
|
| Rate for Payer: Multiplan Commercial |
$8,460.80
|
| Rate for Payer: NAPHCARE Commercial |
$6,345.60
|
| Rate for Payer: Preferred Network Access Commercial |
$9,729.92
|
| Rate for Payer: Quartz Beloit One Network |
$5,182.24
|
| Rate for Payer: Quartz Commercial |
$6,345.60
|
| Rate for Payer: WEA Trust Commercial |
$5,816.80
|
| Rate for Payer: WPS Commercial |
$7,833.64
|
|
|
LINER CONTINUUM VE ELEVATED JJ 36MM X 54 00-8852-011-36
|
Facility
|
OP
|
$10,576.00
|
|
| Hospital Charge Code |
3529521
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,961.28 |
| Max. Negotiated Rate |
$42,304.00 |
| Rate for Payer: Aetna Commercial |
$9,518.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$9,095.36
|
| Rate for Payer: Aetna Managed Medicare |
$2,961.28
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$6,874.40
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$5,288.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$5,076.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,605.28
|
| Rate for Payer: Cash Price |
$3,172.80
|
| Rate for Payer: Cigna Commercial |
$9,729.92
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$5,918.33
|
| Rate for Payer: Health EOS Commercial |
$9,412.64
|
| Rate for Payer: HFN Commercial |
$9,729.92
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$7,932.00
|
| Rate for Payer: Multiplan Commercial |
$8,460.80
|
| Rate for Payer: NAPHCARE Commercial |
$6,345.60
|
| Rate for Payer: Preferred Network Access Commercial |
$9,729.92
|
| Rate for Payer: Quartz Beloit One Network |
$5,182.24
|
| Rate for Payer: Quartz Commercial |
$6,874.40
|
| Rate for Payer: Quartz Medicare Advantage |
$6,345.60
|
| Rate for Payer: The Alliance Commercial |
$42,304.00
|
| Rate for Payer: WEA Trust Commercial |
$5,816.80
|
| Rate for Payer: WPS Commercial |
$7,833.64
|
|
|
LINER CONTINUUM VE ELEVATED JJ 36MM X 54 00-8852-011-36
|
Facility
|
IP
|
$10,576.00
|
|
| Hospital Charge Code |
3529521
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,182.24 |
| Max. Negotiated Rate |
$9,729.92 |
| Rate for Payer: Aetna Commercial |
$9,518.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$9,095.36
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,605.28
|
| Rate for Payer: Cash Price |
$3,172.80
|
| Rate for Payer: Cigna Commercial |
$9,729.92
|
| Rate for Payer: Health EOS Commercial |
$9,412.64
|
| Rate for Payer: HFN Commercial |
$9,729.92
|
| Rate for Payer: Multiplan Commercial |
$8,460.80
|
| Rate for Payer: NAPHCARE Commercial |
$6,345.60
|
| Rate for Payer: Preferred Network Access Commercial |
$9,729.92
|
| Rate for Payer: Quartz Beloit One Network |
$5,182.24
|
| Rate for Payer: Quartz Commercial |
$6,345.60
|
| Rate for Payer: WEA Trust Commercial |
$5,816.80
|
| Rate for Payer: WPS Commercial |
$7,833.64
|
|
|
LINER CONTINUUM VE ELEVATED KK 36MM X 56 00-8852-012-36
|
Facility
|
IP
|
$10,576.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
3583491
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,182.24 |
| Max. Negotiated Rate |
$9,729.92 |
| Rate for Payer: Aetna Commercial |
$9,518.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$9,095.36
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,605.28
|
| Rate for Payer: Cash Price |
$3,172.80
|
| Rate for Payer: Cigna Commercial |
$9,729.92
|
| Rate for Payer: Health EOS Commercial |
$9,412.64
|
| Rate for Payer: HFN Commercial |
$9,729.92
|
| Rate for Payer: Multiplan Commercial |
$8,460.80
|
| Rate for Payer: NAPHCARE Commercial |
$6,345.60
|
| Rate for Payer: Preferred Network Access Commercial |
$9,729.92
|
| Rate for Payer: Quartz Beloit One Network |
$5,182.24
|
| Rate for Payer: Quartz Commercial |
$6,345.60
|
| Rate for Payer: WEA Trust Commercial |
$5,816.80
|
| Rate for Payer: WPS Commercial |
$7,833.64
|
|
|
LINER CONTINUUM VE ELEVATED KK 36MM X 56 00-8852-012-36
|
Facility
|
OP
|
$10,576.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
3583491
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,961.28 |
| Max. Negotiated Rate |
$42,304.00 |
| Rate for Payer: Aetna Commercial |
$9,518.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$9,095.36
|
| Rate for Payer: Aetna Managed Medicare |
$2,961.28
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$6,874.40
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$5,288.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$5,076.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,605.28
|
| Rate for Payer: Cash Price |
$3,172.80
|
| Rate for Payer: Cigna Commercial |
$9,729.92
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$5,918.33
|
| Rate for Payer: Health EOS Commercial |
$9,412.64
|
| Rate for Payer: HFN Commercial |
$9,729.92
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$7,932.00
|
| Rate for Payer: Multiplan Commercial |
$8,460.80
|
| Rate for Payer: NAPHCARE Commercial |
$6,345.60
|
| Rate for Payer: Preferred Network Access Commercial |
$9,729.92
|
| Rate for Payer: Quartz Beloit One Network |
$5,182.24
|
| Rate for Payer: Quartz Commercial |
$6,874.40
|
| Rate for Payer: Quartz Medicare Advantage |
$6,345.60
|
| Rate for Payer: The Alliance Commercial |
$42,304.00
|
| Rate for Payer: WEA Trust Commercial |
$5,816.80
|
| Rate for Payer: WPS Commercial |
$7,833.64
|
|
|
LINER CONTINUUM VE ELEVATED LL 36MM X 58 00-8852-013-36
|
Facility
|
IP
|
$10,576.00
|
|
| Hospital Charge Code |
3365526
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,182.24 |
| Max. Negotiated Rate |
$9,729.92 |
| Rate for Payer: Aetna Commercial |
$9,518.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$9,095.36
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,605.28
|
| Rate for Payer: Cash Price |
$3,172.80
|
| Rate for Payer: Cigna Commercial |
$9,729.92
|
| Rate for Payer: Health EOS Commercial |
$9,412.64
|
| Rate for Payer: HFN Commercial |
$9,729.92
|
| Rate for Payer: Multiplan Commercial |
$8,460.80
|
| Rate for Payer: NAPHCARE Commercial |
$6,345.60
|
| Rate for Payer: Preferred Network Access Commercial |
$9,729.92
|
| Rate for Payer: Quartz Beloit One Network |
$5,182.24
|
| Rate for Payer: Quartz Commercial |
$6,345.60
|
| Rate for Payer: WEA Trust Commercial |
$5,816.80
|
| Rate for Payer: WPS Commercial |
$7,833.64
|
|
|
LINER CONTINUUM VE ELEVATED LL 36MM X 58 00-8852-013-36
|
Facility
|
OP
|
$10,576.00
|
|
| Hospital Charge Code |
3365526
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,961.28 |
| Max. Negotiated Rate |
$42,304.00 |
| Rate for Payer: Aetna Commercial |
$9,518.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$9,095.36
|
| Rate for Payer: Aetna Managed Medicare |
$2,961.28
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$6,874.40
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$5,288.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$5,076.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,605.28
|
| Rate for Payer: Cash Price |
$3,172.80
|
| Rate for Payer: Cigna Commercial |
$9,729.92
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$5,918.33
|
| Rate for Payer: Health EOS Commercial |
$9,412.64
|
| Rate for Payer: HFN Commercial |
$9,729.92
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$7,932.00
|
| Rate for Payer: Multiplan Commercial |
$8,460.80
|
| Rate for Payer: NAPHCARE Commercial |
$6,345.60
|
| Rate for Payer: Preferred Network Access Commercial |
$9,729.92
|
| Rate for Payer: Quartz Beloit One Network |
$5,182.24
|
| Rate for Payer: Quartz Commercial |
$6,874.40
|
| Rate for Payer: Quartz Medicare Advantage |
$6,345.60
|
| Rate for Payer: The Alliance Commercial |
$42,304.00
|
| Rate for Payer: WEA Trust Commercial |
$5,816.80
|
| Rate for Payer: WPS Commercial |
$7,833.64
|
|
|
LINER CONTINUUM VE ELEVATED MM 36MM X 60 00-8852-014-36
|
Facility
|
OP
|
$10,576.00
|
|
| Hospital Charge Code |
3763526
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,961.28 |
| Max. Negotiated Rate |
$42,304.00 |
| Rate for Payer: Aetna Commercial |
$9,518.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$9,095.36
|
| Rate for Payer: Aetna Managed Medicare |
$2,961.28
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$6,874.40
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$5,288.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$5,076.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,605.28
|
| Rate for Payer: Cash Price |
$3,172.80
|
| Rate for Payer: Cigna Commercial |
$9,729.92
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$5,918.33
|
| Rate for Payer: Health EOS Commercial |
$9,412.64
|
| Rate for Payer: HFN Commercial |
$9,729.92
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$7,932.00
|
| Rate for Payer: Multiplan Commercial |
$8,460.80
|
| Rate for Payer: NAPHCARE Commercial |
$6,345.60
|
| Rate for Payer: Preferred Network Access Commercial |
$9,729.92
|
| Rate for Payer: Quartz Beloit One Network |
$5,182.24
|
| Rate for Payer: Quartz Commercial |
$6,874.40
|
| Rate for Payer: Quartz Medicare Advantage |
$6,345.60
|
| Rate for Payer: The Alliance Commercial |
$42,304.00
|
| Rate for Payer: WEA Trust Commercial |
$5,816.80
|
| Rate for Payer: WPS Commercial |
$7,833.64
|
|
|
LINER CONTINUUM VE ELEVATED MM 36MM X 60 00-8852-014-36
|
Facility
|
IP
|
$10,576.00
|
|
| Hospital Charge Code |
3763526
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,182.24 |
| Max. Negotiated Rate |
$9,729.92 |
| Rate for Payer: Aetna Commercial |
$9,518.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$9,095.36
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,605.28
|
| Rate for Payer: Cash Price |
$3,172.80
|
| Rate for Payer: Cigna Commercial |
$9,729.92
|
| Rate for Payer: Health EOS Commercial |
$9,412.64
|
| Rate for Payer: HFN Commercial |
$9,729.92
|
| Rate for Payer: Multiplan Commercial |
$8,460.80
|
| Rate for Payer: NAPHCARE Commercial |
$6,345.60
|
| Rate for Payer: Preferred Network Access Commercial |
$9,729.92
|
| Rate for Payer: Quartz Beloit One Network |
$5,182.24
|
| Rate for Payer: Quartz Commercial |
$6,345.60
|
| Rate for Payer: WEA Trust Commercial |
$5,816.80
|
| Rate for Payer: WPS Commercial |
$7,833.64
|
|
|
LINER CONTINUUM VE ELEVATED NN 36MM 00-8852-015-36
|
Facility
|
IP
|
$10,576.00
|
|
| Hospital Charge Code |
3279475
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,182.24 |
| Max. Negotiated Rate |
$9,729.92 |
| Rate for Payer: Aetna Commercial |
$9,518.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$9,095.36
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,605.28
|
| Rate for Payer: Cash Price |
$3,172.80
|
| Rate for Payer: Cigna Commercial |
$9,729.92
|
| Rate for Payer: Health EOS Commercial |
$9,412.64
|
| Rate for Payer: HFN Commercial |
$9,729.92
|
| Rate for Payer: Multiplan Commercial |
$8,460.80
|
| Rate for Payer: NAPHCARE Commercial |
$6,345.60
|
| Rate for Payer: Preferred Network Access Commercial |
$9,729.92
|
| Rate for Payer: Quartz Beloit One Network |
$5,182.24
|
| Rate for Payer: Quartz Commercial |
$6,345.60
|
| Rate for Payer: WEA Trust Commercial |
$5,816.80
|
| Rate for Payer: WPS Commercial |
$7,833.64
|
|
|
LINER CONTINUUM VE ELEVATED NN 36MM 00-8852-015-36
|
Facility
|
OP
|
$10,576.00
|
|
| Hospital Charge Code |
3279475
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,961.28 |
| Max. Negotiated Rate |
$42,304.00 |
| Rate for Payer: Aetna Commercial |
$9,518.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$9,095.36
|
| Rate for Payer: Aetna Managed Medicare |
$2,961.28
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$6,874.40
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$5,288.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$5,076.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,605.28
|
| Rate for Payer: Cash Price |
$3,172.80
|
| Rate for Payer: Cigna Commercial |
$9,729.92
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$5,918.33
|
| Rate for Payer: Health EOS Commercial |
$9,412.64
|
| Rate for Payer: HFN Commercial |
$9,729.92
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$7,932.00
|
| Rate for Payer: Multiplan Commercial |
$8,460.80
|
| Rate for Payer: NAPHCARE Commercial |
$6,345.60
|
| Rate for Payer: Preferred Network Access Commercial |
$9,729.92
|
| Rate for Payer: Quartz Beloit One Network |
$5,182.24
|
| Rate for Payer: Quartz Commercial |
$6,874.40
|
| Rate for Payer: Quartz Medicare Advantage |
$6,345.60
|
| Rate for Payer: The Alliance Commercial |
$42,304.00
|
| Rate for Payer: WEA Trust Commercial |
$5,816.80
|
| Rate for Payer: WPS Commercial |
$7,833.64
|
|
|
LINER LONG. 32x48 20 DEG ELEV
|
Facility
|
IP
|
$7,272.00
|
|
| Hospital Charge Code |
2967496
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,563.28 |
| Max. Negotiated Rate |
$6,690.24 |
| Rate for Payer: Aetna Commercial |
$6,544.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,253.92
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,854.16
|
| Rate for Payer: Cash Price |
$2,181.60
|
| Rate for Payer: Cigna Commercial |
$6,690.24
|
| Rate for Payer: Health EOS Commercial |
$6,472.08
|
| Rate for Payer: HFN Commercial |
$6,690.24
|
| Rate for Payer: Multiplan Commercial |
$5,817.60
|
| Rate for Payer: NAPHCARE Commercial |
$4,363.20
|
| Rate for Payer: Preferred Network Access Commercial |
$6,690.24
|
| Rate for Payer: Quartz Beloit One Network |
$3,563.28
|
| Rate for Payer: Quartz Commercial |
$4,363.20
|
| Rate for Payer: WEA Trust Commercial |
$3,999.60
|
| Rate for Payer: WPS Commercial |
$5,386.37
|
|
|
LINER LONG. 32x48 20 DEG ELEV
|
Facility
|
OP
|
$7,272.00
|
|
| Hospital Charge Code |
2967496
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,036.16 |
| Max. Negotiated Rate |
$29,088.00 |
| Rate for Payer: Aetna Commercial |
$6,544.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,253.92
|
| Rate for Payer: Aetna Managed Medicare |
$2,036.16
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,726.80
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,636.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,490.56
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,854.16
|
| Rate for Payer: Cash Price |
$2,181.60
|
| Rate for Payer: Cigna Commercial |
$6,690.24
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,069.41
|
| Rate for Payer: Health EOS Commercial |
$6,472.08
|
| Rate for Payer: HFN Commercial |
$6,690.24
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5,454.00
|
| Rate for Payer: Multiplan Commercial |
$5,817.60
|
| Rate for Payer: NAPHCARE Commercial |
$4,363.20
|
| Rate for Payer: Preferred Network Access Commercial |
$6,690.24
|
| Rate for Payer: Quartz Beloit One Network |
$3,563.28
|
| Rate for Payer: Quartz Commercial |
$4,726.80
|
| Rate for Payer: Quartz Medicare Advantage |
$4,363.20
|
| Rate for Payer: The Alliance Commercial |
$29,088.00
|
| Rate for Payer: WEA Trust Commercial |
$3,999.60
|
| Rate for Payer: WPS Commercial |
$5,386.37
|
|
|
LINER LONGEVITY 40x58
|
Facility
|
OP
|
$10,183.00
|
|
| Hospital Charge Code |
2967497
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,851.24 |
| Max. Negotiated Rate |
$40,732.00 |
| Rate for Payer: Aetna Commercial |
$9,164.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$8,757.38
|
| Rate for Payer: Aetna Managed Medicare |
$2,851.24
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$6,618.95
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$5,091.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,887.84
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,396.99
|
| Rate for Payer: Cash Price |
$3,054.90
|
| Rate for Payer: Cigna Commercial |
$9,368.36
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$5,698.41
|
| Rate for Payer: Health EOS Commercial |
$9,062.87
|
| Rate for Payer: HFN Commercial |
$9,368.36
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$7,637.25
|
| Rate for Payer: Multiplan Commercial |
$8,146.40
|
| Rate for Payer: NAPHCARE Commercial |
$6,109.80
|
| Rate for Payer: Preferred Network Access Commercial |
$9,368.36
|
| Rate for Payer: Quartz Beloit One Network |
$4,989.67
|
| Rate for Payer: Quartz Commercial |
$6,618.95
|
| Rate for Payer: Quartz Medicare Advantage |
$6,109.80
|
| Rate for Payer: The Alliance Commercial |
$40,732.00
|
| Rate for Payer: WEA Trust Commercial |
$5,600.65
|
| Rate for Payer: WPS Commercial |
$7,542.55
|
|
|
LINER LONGEVITY 40x58
|
Facility
|
IP
|
$10,183.00
|
|
| Hospital Charge Code |
2967497
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,989.67 |
| Max. Negotiated Rate |
$9,368.36 |
| Rate for Payer: Aetna Commercial |
$9,164.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$8,757.38
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,396.99
|
| Rate for Payer: Cash Price |
$3,054.90
|
| Rate for Payer: Cigna Commercial |
$9,368.36
|
| Rate for Payer: Health EOS Commercial |
$9,062.87
|
| Rate for Payer: HFN Commercial |
$9,368.36
|
| Rate for Payer: Multiplan Commercial |
$8,146.40
|
| Rate for Payer: NAPHCARE Commercial |
$6,109.80
|
| Rate for Payer: Preferred Network Access Commercial |
$9,368.36
|
| Rate for Payer: Quartz Beloit One Network |
$4,989.67
|
| Rate for Payer: Quartz Commercial |
$6,109.80
|
| Rate for Payer: WEA Trust Commercial |
$5,600.65
|
| Rate for Payer: WPS Commercial |
$7,542.55
|
|
|
LINER LONGEVITY 44X28 10 DEG 6310-44-28
|
Facility
|
OP
|
$1,212.00
|
|
| Hospital Charge Code |
2967723
|
|
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 LONGEVITY 44X28 10 DEG 6310-44-28
|
Facility
|
IP
|
$1,212.00
|
|
| Hospital Charge Code |
2967723
|
|
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 LONGEVITY 46X28 10 DEG 6310-46-28
|
Facility
|
IP
|
$1,212.00
|
|
| Hospital Charge Code |
2967724
|
|
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 LONGEVITY 46X28 10 DEG 6310-46-28
|
Facility
|
OP
|
$1,212.00
|
|
| Hospital Charge Code |
2967724
|
|
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
|
|
