|
LINER 50X32 LONGEVITY 10 DEG 6310-50-32
|
Facility
|
IP
|
$1,212.00
|
|
| Hospital Charge Code |
2967731
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$617.64 |
| Max. Negotiated Rate |
$1,159.64 |
| Rate for Payer: Aetna Commercial |
$1,134.43
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,084.01
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$668.05
|
| Rate for Payer: Cash Price |
$363.60
|
| Rate for Payer: Cigna Commercial |
$1,159.64
|
| Rate for Payer: Health EOS Commercial |
$1,121.83
|
| Rate for Payer: HFN Commercial |
$1,159.64
|
| Rate for Payer: Multiplan Commercial |
$1,008.38
|
| Rate for Payer: Preferred Network Access Commercial |
$1,159.64
|
| Rate for Payer: Quartz Beloit One Network |
$617.64
|
| Rate for Payer: Quartz Commercial |
$756.29
|
| Rate for Payer: WEA Trust Commercial |
$693.26
|
| Rate for Payer: WPS Commercial |
$933.60
|
|
|
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 |
$4,684.24 |
| Max. Negotiated Rate |
$8,794.91 |
| Rate for Payer: Aetna Commercial |
$8,603.71
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$8,221.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,066.63
|
| Rate for Payer: Cash Price |
$2,757.60
|
| Rate for Payer: Cigna Commercial |
$8,794.91
|
| Rate for Payer: Health EOS Commercial |
$8,508.12
|
| Rate for Payer: HFN Commercial |
$8,794.91
|
| Rate for Payer: Multiplan Commercial |
$7,647.74
|
| Rate for Payer: Preferred Network Access Commercial |
$8,794.91
|
| Rate for Payer: Quartz Beloit One Network |
$4,684.24
|
| Rate for Payer: Quartz Commercial |
$5,735.81
|
| Rate for Payer: WEA Trust Commercial |
$5,257.82
|
| Rate for Payer: WPS Commercial |
$7,080.60
|
|
|
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 |
$2,676.71 |
| Max. Negotiated Rate |
$8,794.91 |
| Rate for Payer: Aetna Commercial |
$8,603.71
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$8,221.32
|
| Rate for Payer: Aetna Managed Medicare |
$2,676.71
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$6,213.79
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,779.84
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,588.65
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,066.63
|
| Rate for Payer: Cash Price |
$2,757.60
|
| Rate for Payer: Cigna Commercial |
$8,794.91
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$5,349.74
|
| Rate for Payer: Health EOS Commercial |
$8,508.12
|
| Rate for Payer: HFN Commercial |
$8,794.91
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$7,169.76
|
| Rate for Payer: Multiplan Commercial |
$7,647.74
|
| Rate for Payer: NAPHCARE Commercial |
$5,735.81
|
| Rate for Payer: Preferred Network Access Commercial |
$8,794.91
|
| Rate for Payer: Quartz Beloit One Network |
$4,684.24
|
| Rate for Payer: Quartz Commercial |
$6,213.79
|
| Rate for Payer: Quartz Medicare Advantage |
$5,735.81
|
| Rate for Payer: The Alliance Commercial |
$4,779.84
|
| Rate for Payer: WEA Trust Commercial |
$5,257.82
|
| Rate for Payer: WPS Commercial |
$7,080.60
|
|
|
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 |
$5,276.91 |
| Max. Negotiated Rate |
$9,907.66 |
| Rate for Payer: Aetna Commercial |
$9,692.28
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$9,261.51
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,707.68
|
| Rate for Payer: Cash Price |
$3,106.50
|
| Rate for Payer: Cigna Commercial |
$9,907.66
|
| Rate for Payer: Health EOS Commercial |
$9,584.59
|
| Rate for Payer: HFN Commercial |
$9,907.66
|
| Rate for Payer: Multiplan Commercial |
$8,615.36
|
| Rate for Payer: Preferred Network Access Commercial |
$9,907.66
|
| Rate for Payer: Quartz Beloit One Network |
$5,276.91
|
| Rate for Payer: Quartz Commercial |
$6,461.52
|
| Rate for Payer: WEA Trust Commercial |
$5,923.06
|
| Rate for Payer: WPS Commercial |
$7,976.46
|
|
|
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 |
$3,015.38 |
| Max. Negotiated Rate |
$9,907.66 |
| Rate for Payer: Aetna Commercial |
$9,692.28
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$9,261.51
|
| Rate for Payer: Aetna Managed Medicare |
$3,015.38
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$6,999.98
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$5,384.60
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$5,169.22
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,707.68
|
| Rate for Payer: Cash Price |
$3,106.50
|
| Rate for Payer: Cigna Commercial |
$9,907.66
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$6,026.61
|
| Rate for Payer: Health EOS Commercial |
$9,584.59
|
| Rate for Payer: HFN Commercial |
$9,907.66
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$8,076.90
|
| Rate for Payer: Multiplan Commercial |
$8,615.36
|
| Rate for Payer: NAPHCARE Commercial |
$6,461.52
|
| Rate for Payer: Preferred Network Access Commercial |
$9,907.66
|
| Rate for Payer: Quartz Beloit One Network |
$5,276.91
|
| Rate for Payer: Quartz Commercial |
$6,999.98
|
| Rate for Payer: Quartz Medicare Advantage |
$6,461.52
|
| Rate for Payer: The Alliance Commercial |
$5,384.60
|
| Rate for Payer: WEA Trust Commercial |
$5,923.06
|
| Rate for Payer: WPS Commercial |
$7,976.46
|
|
|
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 |
$1,523.70 |
| Max. Negotiated Rate |
$2,860.83 |
| Rate for Payer: Aetna Commercial |
$2,798.64
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,674.26
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,648.09
|
| Rate for Payer: Cash Price |
$897.00
|
| Rate for Payer: Cigna Commercial |
$2,860.83
|
| Rate for Payer: Health EOS Commercial |
$2,767.54
|
| Rate for Payer: HFN Commercial |
$2,860.83
|
| Rate for Payer: Multiplan Commercial |
$2,487.68
|
| Rate for Payer: Preferred Network Access Commercial |
$2,860.83
|
| Rate for Payer: Quartz Beloit One Network |
$1,523.70
|
| Rate for Payer: Quartz Commercial |
$1,865.76
|
| Rate for Payer: WEA Trust Commercial |
$1,710.28
|
| Rate for Payer: WPS Commercial |
$2,303.20
|
|
|
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 |
$870.69 |
| Max. Negotiated Rate |
$2,860.83 |
| Rate for Payer: Aetna Commercial |
$2,798.64
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,674.26
|
| Rate for Payer: Aetna Managed Medicare |
$870.69
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,021.24
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,554.80
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,492.61
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,648.09
|
| Rate for Payer: Cash Price |
$897.00
|
| Rate for Payer: Cigna Commercial |
$2,860.83
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,740.18
|
| Rate for Payer: Health EOS Commercial |
$2,767.54
|
| Rate for Payer: HFN Commercial |
$2,860.83
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,332.20
|
| Rate for Payer: Multiplan Commercial |
$2,487.68
|
| Rate for Payer: NAPHCARE Commercial |
$1,865.76
|
| Rate for Payer: Preferred Network Access Commercial |
$2,860.83
|
| Rate for Payer: Quartz Beloit One Network |
$1,523.70
|
| Rate for Payer: Quartz Commercial |
$2,021.24
|
| Rate for Payer: Quartz Medicare Advantage |
$1,865.76
|
| Rate for Payer: The Alliance Commercial |
$1,554.80
|
| Rate for Payer: WEA Trust Commercial |
$1,710.28
|
| Rate for Payer: WPS Commercial |
$2,303.20
|
|
|
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 |
$2,577.41 |
| Max. Negotiated Rate |
$8,468.64 |
| Rate for Payer: Aetna Commercial |
$8,284.54
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,916.33
|
| Rate for Payer: Aetna Managed Medicare |
$2,577.41
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5,983.28
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,602.52
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,418.42
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,878.67
|
| Rate for Payer: Cash Price |
$2,655.30
|
| Rate for Payer: Cigna Commercial |
$8,468.64
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$5,151.28
|
| Rate for Payer: Health EOS Commercial |
$8,192.49
|
| Rate for Payer: HFN Commercial |
$8,468.64
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$6,903.78
|
| Rate for Payer: Multiplan Commercial |
$7,364.03
|
| Rate for Payer: NAPHCARE Commercial |
$5,523.02
|
| Rate for Payer: Preferred Network Access Commercial |
$8,468.64
|
| Rate for Payer: Quartz Beloit One Network |
$4,510.47
|
| Rate for Payer: Quartz Commercial |
$5,983.28
|
| Rate for Payer: Quartz Medicare Advantage |
$5,523.02
|
| Rate for Payer: The Alliance Commercial |
$4,602.52
|
| Rate for Payer: WEA Trust Commercial |
$5,062.77
|
| Rate for Payer: WPS Commercial |
$6,817.93
|
|
|
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 |
$4,510.47 |
| Max. Negotiated Rate |
$8,468.64 |
| Rate for Payer: Aetna Commercial |
$8,284.54
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,916.33
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,878.67
|
| Rate for Payer: Cash Price |
$2,655.30
|
| Rate for Payer: Cigna Commercial |
$8,468.64
|
| Rate for Payer: Health EOS Commercial |
$8,192.49
|
| Rate for Payer: HFN Commercial |
$8,468.64
|
| Rate for Payer: Multiplan Commercial |
$7,364.03
|
| Rate for Payer: Preferred Network Access Commercial |
$8,468.64
|
| Rate for Payer: Quartz Beloit One Network |
$4,510.47
|
| Rate for Payer: Quartz Commercial |
$5,523.02
|
| Rate for Payer: WEA Trust Commercial |
$5,062.77
|
| Rate for Payer: WPS Commercial |
$6,817.93
|
|
|
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 |
$3,015.38 |
| Max. Negotiated Rate |
$9,907.66 |
| Rate for Payer: Aetna Commercial |
$9,692.28
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$9,261.51
|
| Rate for Payer: Aetna Managed Medicare |
$3,015.38
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$6,999.98
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$5,384.60
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$5,169.22
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,707.68
|
| Rate for Payer: Cash Price |
$3,106.50
|
| Rate for Payer: Cigna Commercial |
$9,907.66
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$6,026.61
|
| Rate for Payer: Health EOS Commercial |
$9,584.59
|
| Rate for Payer: HFN Commercial |
$9,907.66
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$8,076.90
|
| Rate for Payer: Multiplan Commercial |
$8,615.36
|
| Rate for Payer: NAPHCARE Commercial |
$6,461.52
|
| Rate for Payer: Preferred Network Access Commercial |
$9,907.66
|
| Rate for Payer: Quartz Beloit One Network |
$5,276.91
|
| Rate for Payer: Quartz Commercial |
$6,999.98
|
| Rate for Payer: Quartz Medicare Advantage |
$6,461.52
|
| Rate for Payer: The Alliance Commercial |
$5,384.60
|
| Rate for Payer: WEA Trust Commercial |
$5,923.06
|
| Rate for Payer: WPS Commercial |
$7,976.46
|
|
|
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 |
$5,276.91 |
| Max. Negotiated Rate |
$9,907.66 |
| Rate for Payer: Aetna Commercial |
$9,692.28
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$9,261.51
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,707.68
|
| Rate for Payer: Cash Price |
$3,106.50
|
| Rate for Payer: Cigna Commercial |
$9,907.66
|
| Rate for Payer: Health EOS Commercial |
$9,584.59
|
| Rate for Payer: HFN Commercial |
$9,907.66
|
| Rate for Payer: Multiplan Commercial |
$8,615.36
|
| Rate for Payer: Preferred Network Access Commercial |
$9,907.66
|
| Rate for Payer: Quartz Beloit One Network |
$5,276.91
|
| Rate for Payer: Quartz Commercial |
$6,461.52
|
| Rate for Payer: WEA Trust Commercial |
$5,923.06
|
| Rate for Payer: WPS Commercial |
$7,976.46
|
|
|
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 |
$2,577.41 |
| Max. Negotiated Rate |
$8,468.64 |
| Rate for Payer: Aetna Commercial |
$8,284.54
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,916.33
|
| Rate for Payer: Aetna Managed Medicare |
$2,577.41
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5,983.28
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,602.52
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,418.42
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,878.67
|
| Rate for Payer: Cash Price |
$2,655.30
|
| Rate for Payer: Cigna Commercial |
$8,468.64
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$5,151.28
|
| Rate for Payer: Health EOS Commercial |
$8,192.49
|
| Rate for Payer: HFN Commercial |
$8,468.64
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$6,903.78
|
| Rate for Payer: Multiplan Commercial |
$7,364.03
|
| Rate for Payer: NAPHCARE Commercial |
$5,523.02
|
| Rate for Payer: Preferred Network Access Commercial |
$8,468.64
|
| Rate for Payer: Quartz Beloit One Network |
$4,510.47
|
| Rate for Payer: Quartz Commercial |
$5,983.28
|
| Rate for Payer: Quartz Medicare Advantage |
$5,523.02
|
| Rate for Payer: The Alliance Commercial |
$4,602.52
|
| Rate for Payer: WEA Trust Commercial |
$5,062.77
|
| Rate for Payer: WPS Commercial |
$6,817.93
|
|
|
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 |
$4,510.47 |
| Max. Negotiated Rate |
$8,468.64 |
| Rate for Payer: Aetna Commercial |
$8,284.54
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,916.33
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,878.67
|
| Rate for Payer: Cash Price |
$2,655.30
|
| Rate for Payer: Cigna Commercial |
$8,468.64
|
| Rate for Payer: Health EOS Commercial |
$8,192.49
|
| Rate for Payer: HFN Commercial |
$8,468.64
|
| Rate for Payer: Multiplan Commercial |
$7,364.03
|
| Rate for Payer: Preferred Network Access Commercial |
$8,468.64
|
| Rate for Payer: Quartz Beloit One Network |
$4,510.47
|
| Rate for Payer: Quartz Commercial |
$5,523.02
|
| Rate for Payer: WEA Trust Commercial |
$5,062.77
|
| Rate for Payer: WPS Commercial |
$6,817.93
|
|
|
LINER 56X32 LONGEVITY 10 DEG 6310-56-32
|
Facility
|
OP
|
$1,212.00
|
|
| Hospital Charge Code |
2967738
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$352.93 |
| Max. Negotiated Rate |
$1,159.64 |
| Rate for Payer: Aetna Commercial |
$1,134.43
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,084.01
|
| Rate for Payer: Aetna Managed Medicare |
$352.93
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$819.31
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$630.24
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$605.03
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$668.05
|
| Rate for Payer: Cash Price |
$363.60
|
| Rate for Payer: Cigna Commercial |
$1,159.64
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$705.38
|
| Rate for Payer: Health EOS Commercial |
$1,121.83
|
| Rate for Payer: HFN Commercial |
$1,159.64
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$945.36
|
| Rate for Payer: Multiplan Commercial |
$1,008.38
|
| Rate for Payer: NAPHCARE Commercial |
$756.29
|
| Rate for Payer: Preferred Network Access Commercial |
$1,159.64
|
| Rate for Payer: Quartz Beloit One Network |
$617.64
|
| Rate for Payer: Quartz Commercial |
$819.31
|
| Rate for Payer: Quartz Medicare Advantage |
$756.29
|
| Rate for Payer: The Alliance Commercial |
$630.24
|
| Rate for Payer: WEA Trust Commercial |
$693.26
|
| Rate for Payer: WPS Commercial |
$933.60
|
|
|
LINER 56X32 LONGEVITY 10 DEG 6310-56-32
|
Facility
|
IP
|
$1,212.00
|
|
| Hospital Charge Code |
2967738
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$617.64 |
| Max. Negotiated Rate |
$1,159.64 |
| Rate for Payer: Aetna Commercial |
$1,134.43
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,084.01
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$668.05
|
| Rate for Payer: Cash Price |
$363.60
|
| Rate for Payer: Cigna Commercial |
$1,159.64
|
| Rate for Payer: Health EOS Commercial |
$1,121.83
|
| Rate for Payer: HFN Commercial |
$1,159.64
|
| Rate for Payer: Multiplan Commercial |
$1,008.38
|
| Rate for Payer: Preferred Network Access Commercial |
$1,159.64
|
| Rate for Payer: Quartz Beloit One Network |
$617.64
|
| Rate for Payer: Quartz Commercial |
$756.29
|
| Rate for Payer: WEA Trust Commercial |
$693.26
|
| Rate for Payer: WPS Commercial |
$933.60
|
|
|
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 |
$870.69 |
| Max. Negotiated Rate |
$2,860.83 |
| Rate for Payer: Aetna Commercial |
$2,798.64
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,674.26
|
| Rate for Payer: Aetna Managed Medicare |
$870.69
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,021.24
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,554.80
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,492.61
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,648.09
|
| Rate for Payer: Cash Price |
$897.00
|
| Rate for Payer: Cigna Commercial |
$2,860.83
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,740.18
|
| Rate for Payer: Health EOS Commercial |
$2,767.54
|
| Rate for Payer: HFN Commercial |
$2,860.83
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,332.20
|
| Rate for Payer: Multiplan Commercial |
$2,487.68
|
| Rate for Payer: NAPHCARE Commercial |
$1,865.76
|
| Rate for Payer: Preferred Network Access Commercial |
$2,860.83
|
| Rate for Payer: Quartz Beloit One Network |
$1,523.70
|
| Rate for Payer: Quartz Commercial |
$2,021.24
|
| Rate for Payer: Quartz Medicare Advantage |
$1,865.76
|
| Rate for Payer: The Alliance Commercial |
$1,554.80
|
| Rate for Payer: WEA Trust Commercial |
$1,710.28
|
| Rate for Payer: WPS Commercial |
$2,303.20
|
|
|
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 |
$1,523.70 |
| Max. Negotiated Rate |
$2,860.83 |
| Rate for Payer: Aetna Commercial |
$2,798.64
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,674.26
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,648.09
|
| Rate for Payer: Cash Price |
$897.00
|
| Rate for Payer: Cigna Commercial |
$2,860.83
|
| Rate for Payer: Health EOS Commercial |
$2,767.54
|
| Rate for Payer: HFN Commercial |
$2,860.83
|
| Rate for Payer: Multiplan Commercial |
$2,487.68
|
| Rate for Payer: Preferred Network Access Commercial |
$2,860.83
|
| Rate for Payer: Quartz Beloit One Network |
$1,523.70
|
| Rate for Payer: Quartz Commercial |
$1,865.76
|
| Rate for Payer: WEA Trust Commercial |
$1,710.28
|
| Rate for Payer: WPS Commercial |
$2,303.20
|
|
|
LINER 58X32 10DEG 6310-58-32
|
Facility
|
OP
|
$1,212.00
|
|
| Hospital Charge Code |
2967550
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$352.93 |
| Max. Negotiated Rate |
$1,159.64 |
| Rate for Payer: Aetna Commercial |
$1,134.43
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,084.01
|
| Rate for Payer: Aetna Managed Medicare |
$352.93
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$819.31
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$630.24
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$605.03
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$668.05
|
| Rate for Payer: Cash Price |
$363.60
|
| Rate for Payer: Cigna Commercial |
$1,159.64
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$705.38
|
| Rate for Payer: Health EOS Commercial |
$1,121.83
|
| Rate for Payer: HFN Commercial |
$1,159.64
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$945.36
|
| Rate for Payer: Multiplan Commercial |
$1,008.38
|
| Rate for Payer: NAPHCARE Commercial |
$756.29
|
| Rate for Payer: Preferred Network Access Commercial |
$1,159.64
|
| Rate for Payer: Quartz Beloit One Network |
$617.64
|
| Rate for Payer: Quartz Commercial |
$819.31
|
| Rate for Payer: Quartz Medicare Advantage |
$756.29
|
| Rate for Payer: The Alliance Commercial |
$630.24
|
| Rate for Payer: WEA Trust Commercial |
$693.26
|
| Rate for Payer: WPS Commercial |
$933.60
|
|
|
LINER 58X32 10DEG 6310-58-32
|
Facility
|
IP
|
$1,212.00
|
|
| Hospital Charge Code |
2967550
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$617.64 |
| Max. Negotiated Rate |
$1,159.64 |
| Rate for Payer: Aetna Commercial |
$1,134.43
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,084.01
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$668.05
|
| Rate for Payer: Cash Price |
$363.60
|
| Rate for Payer: Cigna Commercial |
$1,159.64
|
| Rate for Payer: Health EOS Commercial |
$1,121.83
|
| Rate for Payer: HFN Commercial |
$1,159.64
|
| Rate for Payer: Multiplan Commercial |
$1,008.38
|
| Rate for Payer: Preferred Network Access Commercial |
$1,159.64
|
| Rate for Payer: Quartz Beloit One Network |
$617.64
|
| Rate for Payer: Quartz Commercial |
$756.29
|
| Rate for Payer: WEA Trust Commercial |
$693.26
|
| Rate for Payer: WPS Commercial |
$933.60
|
|
|
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 |
$4,510.47 |
| Max. Negotiated Rate |
$8,468.64 |
| Rate for Payer: Aetna Commercial |
$8,284.54
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,916.33
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,878.67
|
| Rate for Payer: Cash Price |
$2,655.30
|
| Rate for Payer: Cigna Commercial |
$8,468.64
|
| Rate for Payer: Health EOS Commercial |
$8,192.49
|
| Rate for Payer: HFN Commercial |
$8,468.64
|
| Rate for Payer: Multiplan Commercial |
$7,364.03
|
| Rate for Payer: Preferred Network Access Commercial |
$8,468.64
|
| Rate for Payer: Quartz Beloit One Network |
$4,510.47
|
| Rate for Payer: Quartz Commercial |
$5,523.02
|
| Rate for Payer: WEA Trust Commercial |
$5,062.77
|
| Rate for Payer: WPS Commercial |
$6,817.93
|
|
|
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 |
$2,577.41 |
| Max. Negotiated Rate |
$8,468.64 |
| Rate for Payer: Aetna Commercial |
$8,284.54
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,916.33
|
| Rate for Payer: Aetna Managed Medicare |
$2,577.41
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5,983.28
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,602.52
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,418.42
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,878.67
|
| Rate for Payer: Cash Price |
$2,655.30
|
| Rate for Payer: Cigna Commercial |
$8,468.64
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$5,151.28
|
| Rate for Payer: Health EOS Commercial |
$8,192.49
|
| Rate for Payer: HFN Commercial |
$8,468.64
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$6,903.78
|
| Rate for Payer: Multiplan Commercial |
$7,364.03
|
| Rate for Payer: NAPHCARE Commercial |
$5,523.02
|
| Rate for Payer: Preferred Network Access Commercial |
$8,468.64
|
| Rate for Payer: Quartz Beloit One Network |
$4,510.47
|
| Rate for Payer: Quartz Commercial |
$5,983.28
|
| Rate for Payer: Quartz Medicare Advantage |
$5,523.02
|
| Rate for Payer: The Alliance Commercial |
$4,602.52
|
| Rate for Payer: WEA Trust Commercial |
$5,062.77
|
| Rate for Payer: WPS Commercial |
$6,817.93
|
|
|
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 |
$1,523.70 |
| Max. Negotiated Rate |
$2,860.83 |
| Rate for Payer: Aetna Commercial |
$2,798.64
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,674.26
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,648.09
|
| Rate for Payer: Cash Price |
$897.00
|
| Rate for Payer: Cigna Commercial |
$2,860.83
|
| Rate for Payer: Health EOS Commercial |
$2,767.54
|
| Rate for Payer: HFN Commercial |
$2,860.83
|
| Rate for Payer: Multiplan Commercial |
$2,487.68
|
| Rate for Payer: Preferred Network Access Commercial |
$2,860.83
|
| Rate for Payer: Quartz Beloit One Network |
$1,523.70
|
| Rate for Payer: Quartz Commercial |
$1,865.76
|
| Rate for Payer: WEA Trust Commercial |
$1,710.28
|
| Rate for Payer: WPS Commercial |
$2,303.20
|
|
|
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 |
$870.69 |
| Max. Negotiated Rate |
$2,860.83 |
| Rate for Payer: Aetna Commercial |
$2,798.64
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,674.26
|
| Rate for Payer: Aetna Managed Medicare |
$870.69
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,021.24
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,554.80
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,492.61
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,648.09
|
| Rate for Payer: Cash Price |
$897.00
|
| Rate for Payer: Cigna Commercial |
$2,860.83
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,740.18
|
| Rate for Payer: Health EOS Commercial |
$2,767.54
|
| Rate for Payer: HFN Commercial |
$2,860.83
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,332.20
|
| Rate for Payer: Multiplan Commercial |
$2,487.68
|
| Rate for Payer: NAPHCARE Commercial |
$1,865.76
|
| Rate for Payer: Preferred Network Access Commercial |
$2,860.83
|
| Rate for Payer: Quartz Beloit One Network |
$1,523.70
|
| Rate for Payer: Quartz Commercial |
$2,021.24
|
| Rate for Payer: Quartz Medicare Advantage |
$1,865.76
|
| Rate for Payer: The Alliance Commercial |
$1,554.80
|
| Rate for Payer: WEA Trust Commercial |
$1,710.28
|
| Rate for Payer: WPS Commercial |
$2,303.20
|
|
|
LINER 60X32 10DEG 6310-60-32
|
Facility
|
IP
|
$1,212.00
|
|
| Hospital Charge Code |
2967551
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$617.64 |
| Max. Negotiated Rate |
$1,159.64 |
| Rate for Payer: Aetna Commercial |
$1,134.43
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,084.01
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$668.05
|
| Rate for Payer: Cash Price |
$363.60
|
| Rate for Payer: Cigna Commercial |
$1,159.64
|
| Rate for Payer: Health EOS Commercial |
$1,121.83
|
| Rate for Payer: HFN Commercial |
$1,159.64
|
| Rate for Payer: Multiplan Commercial |
$1,008.38
|
| Rate for Payer: Preferred Network Access Commercial |
$1,159.64
|
| Rate for Payer: Quartz Beloit One Network |
$617.64
|
| Rate for Payer: Quartz Commercial |
$756.29
|
| Rate for Payer: WEA Trust Commercial |
$693.26
|
| Rate for Payer: WPS Commercial |
$933.60
|
|
|
LINER 60X32 10DEG 6310-60-32
|
Facility
|
OP
|
$1,212.00
|
|
| Hospital Charge Code |
2967551
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$352.93 |
| Max. Negotiated Rate |
$1,159.64 |
| Rate for Payer: Aetna Commercial |
$1,134.43
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,084.01
|
| Rate for Payer: Aetna Managed Medicare |
$352.93
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$819.31
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$630.24
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$605.03
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$668.05
|
| Rate for Payer: Cash Price |
$363.60
|
| Rate for Payer: Cigna Commercial |
$1,159.64
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$705.38
|
| Rate for Payer: Health EOS Commercial |
$1,121.83
|
| Rate for Payer: HFN Commercial |
$1,159.64
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$945.36
|
| Rate for Payer: Multiplan Commercial |
$1,008.38
|
| Rate for Payer: NAPHCARE Commercial |
$756.29
|
| Rate for Payer: Preferred Network Access Commercial |
$1,159.64
|
| Rate for Payer: Quartz Beloit One Network |
$617.64
|
| Rate for Payer: Quartz Commercial |
$819.31
|
| Rate for Payer: Quartz Medicare Advantage |
$756.29
|
| Rate for Payer: The Alliance Commercial |
$630.24
|
| Rate for Payer: WEA Trust Commercial |
$693.26
|
| Rate for Payer: WPS Commercial |
$933.60
|
|
