|
Tick-Borne DNA Panel, PCR, Blood to Mayo
|
Professional
|
Both
|
$405.00
|
|
|
Service Code
|
CPT 87798
|
| Hospital Charge Code |
3591523
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$123.87 |
| Max. Negotiated Rate |
$384.75 |
| Rate for Payer: Aetna Commercial |
$384.75
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$348.30
|
| Rate for Payer: Cash Price |
$121.50
|
| Rate for Payer: Cash Price |
$121.50
|
| Rate for Payer: Cigna Commercial |
$384.75
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$202.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$243.00
|
| Rate for Payer: Health EOS Commercial |
$368.55
|
| Rate for Payer: HFN Commercial |
$384.75
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$123.87
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$123.87
|
| Rate for Payer: Multiplan Commercial |
$324.00
|
| Rate for Payer: Preferred Network Access Commercial |
$384.75
|
| Rate for Payer: Quartz Beloit One Network |
$178.20
|
| Rate for Payer: Quartz Commercial |
$230.85
|
| Rate for Payer: The Alliance Commercial |
$202.50
|
| Rate for Payer: WEA Trust Commercial |
$222.75
|
| Rate for Payer: WPS Commercial |
$299.98
|
|
|
Tick-Borne DNA Panel, PCR, Blood to Mayo
|
Facility
|
OP
|
$405.00
|
|
|
Service Code
|
CPT 87798
|
| Hospital Charge Code |
3591523
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$35.09 |
| Max. Negotiated Rate |
$372.60 |
| Rate for Payer: Aetna Commercial |
$364.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$348.30
|
| Rate for Payer: Aetna Managed Medicare |
$35.09
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$131.59
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$61.41
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$58.25
|
| Rate for Payer: Anthem Medicaid |
$36.26
|
| Rate for Payer: Anthem Medicare Advantage |
$35.09
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$214.65
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$35.09
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$35.09
|
| Rate for Payer: Cash Price |
$121.50
|
| Rate for Payer: Cash Price |
$121.50
|
| Rate for Payer: Cigna Commercial |
$372.60
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$35.09
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$36.26
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$226.64
|
| Rate for Payer: Dean Health Medicaid |
$36.26
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$35.09
|
| Rate for Payer: Health EOS Commercial |
$360.45
|
| Rate for Payer: HFN Commercial |
$372.60
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$130.53
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$35.09
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$36.26
|
| Rate for Payer: Independent Care Health Plan Medicare |
$35.09
|
| Rate for Payer: Managed Health Services Medicaid |
$37.71
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$35.09
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$35.09
|
| Rate for Payer: Multiplan Commercial |
$324.00
|
| Rate for Payer: NAPHCARE Commercial |
$52.64
|
| Rate for Payer: Preferred Network Access Commercial |
$372.60
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$36.26
|
| Rate for Payer: Quartz Beloit One Network |
$198.45
|
| Rate for Payer: Quartz Commercial |
$263.25
|
| Rate for Payer: Quartz Medicare Advantage |
$35.09
|
| Rate for Payer: The Alliance Commercial |
$140.36
|
| Rate for Payer: United Healthcare Medicaid |
$36.26
|
| Rate for Payer: United Healthcare Medicare Advantage |
$35.09
|
| Rate for Payer: United Healthcare PPO |
$303.75
|
| Rate for Payer: WEA Trust Commercial |
$222.75
|
| Rate for Payer: Wellcare Medicare |
$35.09
|
| Rate for Payer: WMAP Medicaid |
$36.26
|
| Rate for Payer: WPS Commercial |
$299.98
|
|
|
Tick ID w/ Reflex Lyme Disease DNA, Real Time PCR, Tick
|
Facility
|
OP
|
$90.00
|
|
|
Service Code
|
CPT 87168
|
| Hospital Charge Code |
3398170
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$4.27 |
| Max. Negotiated Rate |
$82.80 |
| Rate for Payer: Aetna Commercial |
$81.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$77.40
|
| Rate for Payer: Aetna Managed Medicare |
$4.27
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$16.01
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$7.47
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$7.09
|
| Rate for Payer: Anthem Medicaid |
$4.41
|
| Rate for Payer: Anthem Medicare Advantage |
$4.27
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$47.70
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$4.27
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$4.27
|
| Rate for Payer: Cash Price |
$27.00
|
| Rate for Payer: Cash Price |
$27.00
|
| Rate for Payer: Cigna Commercial |
$82.80
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$4.27
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$4.41
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$50.36
|
| Rate for Payer: Dean Health Medicaid |
$4.41
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$4.27
|
| Rate for Payer: Health EOS Commercial |
$80.10
|
| Rate for Payer: HFN Commercial |
$82.80
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$15.88
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$4.27
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$4.41
|
| Rate for Payer: Independent Care Health Plan Medicare |
$4.27
|
| Rate for Payer: Managed Health Services Medicaid |
$4.59
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$4.27
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$4.27
|
| Rate for Payer: Multiplan Commercial |
$72.00
|
| Rate for Payer: NAPHCARE Commercial |
$6.40
|
| Rate for Payer: Preferred Network Access Commercial |
$82.80
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$4.41
|
| Rate for Payer: Quartz Beloit One Network |
$44.10
|
| Rate for Payer: Quartz Commercial |
$58.50
|
| Rate for Payer: Quartz Medicare Advantage |
$4.27
|
| Rate for Payer: The Alliance Commercial |
$17.08
|
| Rate for Payer: United Healthcare Medicaid |
$4.41
|
| Rate for Payer: United Healthcare Medicare Advantage |
$4.27
|
| Rate for Payer: United Healthcare PPO |
$67.50
|
| Rate for Payer: WEA Trust Commercial |
$49.50
|
| Rate for Payer: Wellcare Medicare |
$4.27
|
| Rate for Payer: WMAP Medicaid |
$4.41
|
| Rate for Payer: WPS Commercial |
$66.66
|
|
|
Tick ID w/ Reflex Lyme Disease DNA, Real Time PCR, Tick
|
Facility
|
IP
|
$90.00
|
|
|
Service Code
|
CPT 87168
|
| Hospital Charge Code |
3398170
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$44.10 |
| Max. Negotiated Rate |
$82.80 |
| Rate for Payer: Aetna Commercial |
$81.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$77.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$47.70
|
| Rate for Payer: Cash Price |
$27.00
|
| Rate for Payer: Cigna Commercial |
$82.80
|
| Rate for Payer: Health EOS Commercial |
$80.10
|
| Rate for Payer: HFN Commercial |
$82.80
|
| Rate for Payer: Multiplan Commercial |
$72.00
|
| Rate for Payer: NAPHCARE Commercial |
$54.00
|
| Rate for Payer: Preferred Network Access Commercial |
$82.80
|
| Rate for Payer: Quartz Beloit One Network |
$44.10
|
| Rate for Payer: Quartz Commercial |
$54.00
|
| Rate for Payer: WEA Trust Commercial |
$49.50
|
| Rate for Payer: WPS Commercial |
$66.66
|
|
|
Tick ID w/ Reflex Lyme Disease DNA, Real Time PCR, Tick
|
Professional
|
Both
|
$90.00
|
|
|
Service Code
|
CPT 87168
|
| Hospital Charge Code |
3398170
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$15.07 |
| Max. Negotiated Rate |
$85.50 |
| Rate for Payer: Aetna Commercial |
$85.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$77.40
|
| Rate for Payer: Cash Price |
$27.00
|
| Rate for Payer: Cash Price |
$27.00
|
| Rate for Payer: Cigna Commercial |
$85.50
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$45.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$54.00
|
| Rate for Payer: Health EOS Commercial |
$81.90
|
| Rate for Payer: HFN Commercial |
$85.50
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$15.07
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$15.07
|
| Rate for Payer: Multiplan Commercial |
$72.00
|
| Rate for Payer: Preferred Network Access Commercial |
$85.50
|
| Rate for Payer: Quartz Beloit One Network |
$39.60
|
| Rate for Payer: Quartz Commercial |
$51.30
|
| Rate for Payer: The Alliance Commercial |
$45.00
|
| Rate for Payer: WEA Trust Commercial |
$49.50
|
| Rate for Payer: WPS Commercial |
$66.66
|
|
|
TIGERTAPE #2 BLUE
|
Facility
|
OP
|
$1,180.00
|
|
| Hospital Charge Code |
2967903
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$330.40 |
| Max. Negotiated Rate |
$4,720.00 |
| Rate for Payer: Aetna Commercial |
$1,062.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,014.80
|
| Rate for Payer: Aetna Managed Medicare |
$330.40
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$767.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$590.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$566.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$625.40
|
| Rate for Payer: Cash Price |
$354.00
|
| Rate for Payer: Cigna Commercial |
$1,085.60
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$660.33
|
| Rate for Payer: Health EOS Commercial |
$1,050.20
|
| Rate for Payer: HFN Commercial |
$1,085.60
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$885.00
|
| Rate for Payer: Multiplan Commercial |
$944.00
|
| Rate for Payer: NAPHCARE Commercial |
$708.00
|
| Rate for Payer: Preferred Network Access Commercial |
$1,085.60
|
| Rate for Payer: Quartz Beloit One Network |
$578.20
|
| Rate for Payer: Quartz Commercial |
$767.00
|
| Rate for Payer: Quartz Medicare Advantage |
$708.00
|
| Rate for Payer: The Alliance Commercial |
$4,720.00
|
| Rate for Payer: WEA Trust Commercial |
$649.00
|
| Rate for Payer: WPS Commercial |
$874.03
|
|
|
TIGERTAPE #2 BLUE
|
Facility
|
IP
|
$1,180.00
|
|
| Hospital Charge Code |
2967903
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$578.20 |
| Max. Negotiated Rate |
$1,085.60 |
| Rate for Payer: Aetna Commercial |
$1,062.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,014.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$625.40
|
| Rate for Payer: Cash Price |
$354.00
|
| Rate for Payer: Cigna Commercial |
$1,085.60
|
| Rate for Payer: Health EOS Commercial |
$1,050.20
|
| Rate for Payer: HFN Commercial |
$1,085.60
|
| Rate for Payer: Multiplan Commercial |
$944.00
|
| Rate for Payer: NAPHCARE Commercial |
$708.00
|
| Rate for Payer: Preferred Network Access Commercial |
$1,085.60
|
| Rate for Payer: Quartz Beloit One Network |
$578.20
|
| Rate for Payer: Quartz Commercial |
$708.00
|
| Rate for Payer: WEA Trust Commercial |
$649.00
|
| Rate for Payer: WPS Commercial |
$874.03
|
|
|
TIGERTAPE CERCLAGE SUTURE (BLUE) AR-7267
|
Facility
|
OP
|
$4,603.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
5804368
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,288.84 |
| Max. Negotiated Rate |
$18,412.00 |
| Rate for Payer: Aetna Commercial |
$4,142.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,958.58
|
| Rate for Payer: Aetna Managed Medicare |
$1,288.84
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,991.95
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,301.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,209.44
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,439.59
|
| Rate for Payer: Cash Price |
$1,380.90
|
| Rate for Payer: Cigna Commercial |
$4,234.76
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,575.84
|
| Rate for Payer: Health EOS Commercial |
$4,096.67
|
| Rate for Payer: HFN Commercial |
$4,234.76
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,452.25
|
| Rate for Payer: Multiplan Commercial |
$3,682.40
|
| Rate for Payer: NAPHCARE Commercial |
$2,761.80
|
| Rate for Payer: Preferred Network Access Commercial |
$4,234.76
|
| Rate for Payer: Quartz Beloit One Network |
$2,255.47
|
| Rate for Payer: Quartz Commercial |
$2,991.95
|
| Rate for Payer: Quartz Medicare Advantage |
$2,761.80
|
| Rate for Payer: The Alliance Commercial |
$18,412.00
|
| Rate for Payer: WEA Trust Commercial |
$2,531.65
|
| Rate for Payer: WPS Commercial |
$3,409.44
|
|
|
TIGERTAPE CERCLAGE SUTURE (BLUE) AR-7267
|
Facility
|
IP
|
$4,603.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
5804368
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,255.47 |
| Max. Negotiated Rate |
$4,234.76 |
| Rate for Payer: Aetna Commercial |
$4,142.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,958.58
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,439.59
|
| Rate for Payer: Cash Price |
$1,380.90
|
| Rate for Payer: Cigna Commercial |
$4,234.76
|
| Rate for Payer: Health EOS Commercial |
$4,096.67
|
| Rate for Payer: HFN Commercial |
$4,234.76
|
| Rate for Payer: Multiplan Commercial |
$3,682.40
|
| Rate for Payer: NAPHCARE Commercial |
$2,761.80
|
| Rate for Payer: Preferred Network Access Commercial |
$4,234.76
|
| Rate for Payer: Quartz Beloit One Network |
$2,255.47
|
| Rate for Payer: Quartz Commercial |
$2,761.80
|
| Rate for Payer: WEA Trust Commercial |
$2,531.65
|
| Rate for Payer: WPS Commercial |
$3,409.44
|
|
|
TIGERTAPE CERCLAGE SUTURE (WHITE/BLACK) AR-7267T
|
Facility
|
IP
|
$4,603.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
5803670
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,255.47 |
| Max. Negotiated Rate |
$4,234.76 |
| Rate for Payer: Aetna Commercial |
$4,142.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,958.58
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,439.59
|
| Rate for Payer: Cash Price |
$1,380.90
|
| Rate for Payer: Cigna Commercial |
$4,234.76
|
| Rate for Payer: Health EOS Commercial |
$4,096.67
|
| Rate for Payer: HFN Commercial |
$4,234.76
|
| Rate for Payer: Multiplan Commercial |
$3,682.40
|
| Rate for Payer: NAPHCARE Commercial |
$2,761.80
|
| Rate for Payer: Preferred Network Access Commercial |
$4,234.76
|
| Rate for Payer: Quartz Beloit One Network |
$2,255.47
|
| Rate for Payer: Quartz Commercial |
$2,761.80
|
| Rate for Payer: WEA Trust Commercial |
$2,531.65
|
| Rate for Payer: WPS Commercial |
$3,409.44
|
|
|
TIGERTAPE CERCLAGE SUTURE (WHITE/BLACK) AR-7267T
|
Facility
|
OP
|
$4,603.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
5803670
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,288.84 |
| Max. Negotiated Rate |
$18,412.00 |
| Rate for Payer: Aetna Commercial |
$4,142.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,958.58
|
| Rate for Payer: Aetna Managed Medicare |
$1,288.84
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,991.95
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,301.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,209.44
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,439.59
|
| Rate for Payer: Cash Price |
$1,380.90
|
| Rate for Payer: Cigna Commercial |
$4,234.76
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,575.84
|
| Rate for Payer: Health EOS Commercial |
$4,096.67
|
| Rate for Payer: HFN Commercial |
$4,234.76
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,452.25
|
| Rate for Payer: Multiplan Commercial |
$3,682.40
|
| Rate for Payer: NAPHCARE Commercial |
$2,761.80
|
| Rate for Payer: Preferred Network Access Commercial |
$4,234.76
|
| Rate for Payer: Quartz Beloit One Network |
$2,255.47
|
| Rate for Payer: Quartz Commercial |
$2,991.95
|
| Rate for Payer: Quartz Medicare Advantage |
$2,761.80
|
| Rate for Payer: The Alliance Commercial |
$18,412.00
|
| Rate for Payer: WEA Trust Commercial |
$2,531.65
|
| Rate for Payer: WPS Commercial |
$3,409.44
|
|
|
TIGERTAPE CERCLAGE SUTURE W/O NEEDLE AR-7268
|
Facility
|
IP
|
$4,672.00
|
|
| Hospital Charge Code |
6166114
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$2,289.28 |
| Max. Negotiated Rate |
$4,298.24 |
| Rate for Payer: Aetna Commercial |
$4,204.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,017.92
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,476.16
|
| Rate for Payer: Cash Price |
$1,401.60
|
| Rate for Payer: Cigna Commercial |
$4,298.24
|
| Rate for Payer: Health EOS Commercial |
$4,158.08
|
| Rate for Payer: HFN Commercial |
$4,298.24
|
| Rate for Payer: Multiplan Commercial |
$3,737.60
|
| Rate for Payer: NAPHCARE Commercial |
$2,803.20
|
| Rate for Payer: Preferred Network Access Commercial |
$4,298.24
|
| Rate for Payer: Quartz Beloit One Network |
$2,289.28
|
| Rate for Payer: Quartz Commercial |
$2,803.20
|
| Rate for Payer: WEA Trust Commercial |
$2,569.60
|
| Rate for Payer: WPS Commercial |
$3,460.55
|
|
|
TIGERTAPE CERCLAGE SUTURE W/O NEEDLE AR-7268
|
Facility
|
OP
|
$4,672.00
|
|
| Hospital Charge Code |
6166114
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,308.16 |
| Max. Negotiated Rate |
$18,688.00 |
| Rate for Payer: Aetna Commercial |
$4,204.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,017.92
|
| Rate for Payer: Aetna Managed Medicare |
$1,308.16
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,036.80
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,336.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,242.56
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,476.16
|
| Rate for Payer: Cash Price |
$1,401.60
|
| Rate for Payer: Cigna Commercial |
$4,298.24
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,614.45
|
| Rate for Payer: Health EOS Commercial |
$4,158.08
|
| Rate for Payer: HFN Commercial |
$4,298.24
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,504.00
|
| Rate for Payer: Multiplan Commercial |
$3,737.60
|
| Rate for Payer: NAPHCARE Commercial |
$2,803.20
|
| Rate for Payer: Preferred Network Access Commercial |
$4,298.24
|
| Rate for Payer: Quartz Beloit One Network |
$2,289.28
|
| Rate for Payer: Quartz Commercial |
$3,036.80
|
| Rate for Payer: Quartz Medicare Advantage |
$2,803.20
|
| Rate for Payer: The Alliance Commercial |
$18,688.00
|
| Rate for Payer: WEA Trust Commercial |
$2,569.60
|
| Rate for Payer: WPS Commercial |
$3,460.55
|
|
|
TIGHTROPE ABS 14MM BUTTON ROUND CONCAVE AR-1588TB-4
|
Facility
|
OP
|
$2,383.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
5349532
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$667.24 |
| Max. Negotiated Rate |
$9,532.00 |
| Rate for Payer: Aetna Commercial |
$2,144.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,049.38
|
| Rate for Payer: Aetna Managed Medicare |
$667.24
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,548.95
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,191.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,143.84
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,262.99
|
| Rate for Payer: Cash Price |
$714.90
|
| Rate for Payer: Cigna Commercial |
$2,192.36
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,333.53
|
| Rate for Payer: Health EOS Commercial |
$2,120.87
|
| Rate for Payer: HFN Commercial |
$2,192.36
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,787.25
|
| Rate for Payer: Multiplan Commercial |
$1,906.40
|
| Rate for Payer: NAPHCARE Commercial |
$1,429.80
|
| Rate for Payer: Preferred Network Access Commercial |
$2,192.36
|
| Rate for Payer: Quartz Beloit One Network |
$1,167.67
|
| Rate for Payer: Quartz Commercial |
$1,548.95
|
| Rate for Payer: Quartz Medicare Advantage |
$1,429.80
|
| Rate for Payer: The Alliance Commercial |
$9,532.00
|
| Rate for Payer: WEA Trust Commercial |
$1,310.65
|
| Rate for Payer: WPS Commercial |
$1,765.09
|
|
|
TIGHTROPE ABS 14MM BUTTON ROUND CONCAVE AR-1588TB-4
|
Facility
|
IP
|
$2,383.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
5349532
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,167.67 |
| Max. Negotiated Rate |
$2,192.36 |
| Rate for Payer: Aetna Commercial |
$2,144.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,049.38
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,262.99
|
| Rate for Payer: Cash Price |
$714.90
|
| Rate for Payer: Cigna Commercial |
$2,192.36
|
| Rate for Payer: Health EOS Commercial |
$2,120.87
|
| Rate for Payer: HFN Commercial |
$2,192.36
|
| Rate for Payer: Multiplan Commercial |
$1,906.40
|
| Rate for Payer: NAPHCARE Commercial |
$1,429.80
|
| Rate for Payer: Preferred Network Access Commercial |
$2,192.36
|
| Rate for Payer: Quartz Beloit One Network |
$1,167.67
|
| Rate for Payer: Quartz Commercial |
$1,429.80
|
| Rate for Payer: WEA Trust Commercial |
$1,310.65
|
| Rate for Payer: WPS Commercial |
$1,765.09
|
|
|
TIGHTROPE ABS 20MM BUTTON ROUND CONCAVE AR-1588TB-5
|
Facility
|
OP
|
$2,383.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
5459575
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$667.24 |
| Max. Negotiated Rate |
$9,532.00 |
| Rate for Payer: Aetna Commercial |
$2,144.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,049.38
|
| Rate for Payer: Aetna Managed Medicare |
$667.24
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,548.95
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,191.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,143.84
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,262.99
|
| Rate for Payer: Cash Price |
$714.90
|
| Rate for Payer: Cigna Commercial |
$2,192.36
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,333.53
|
| Rate for Payer: Health EOS Commercial |
$2,120.87
|
| Rate for Payer: HFN Commercial |
$2,192.36
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,787.25
|
| Rate for Payer: Multiplan Commercial |
$1,906.40
|
| Rate for Payer: NAPHCARE Commercial |
$1,429.80
|
| Rate for Payer: Preferred Network Access Commercial |
$2,192.36
|
| Rate for Payer: Quartz Beloit One Network |
$1,167.67
|
| Rate for Payer: Quartz Commercial |
$1,548.95
|
| Rate for Payer: Quartz Medicare Advantage |
$1,429.80
|
| Rate for Payer: The Alliance Commercial |
$9,532.00
|
| Rate for Payer: WEA Trust Commercial |
$1,310.65
|
| Rate for Payer: WPS Commercial |
$1,765.09
|
|
|
TIGHTROPE ABS 20MM BUTTON ROUND CONCAVE AR-1588TB-5
|
Facility
|
IP
|
$2,383.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
5459575
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,167.67 |
| Max. Negotiated Rate |
$2,192.36 |
| Rate for Payer: Aetna Commercial |
$2,144.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,049.38
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,262.99
|
| Rate for Payer: Cash Price |
$714.90
|
| Rate for Payer: Cigna Commercial |
$2,192.36
|
| Rate for Payer: Health EOS Commercial |
$2,120.87
|
| Rate for Payer: HFN Commercial |
$2,192.36
|
| Rate for Payer: Multiplan Commercial |
$1,906.40
|
| Rate for Payer: NAPHCARE Commercial |
$1,429.80
|
| Rate for Payer: Preferred Network Access Commercial |
$2,192.36
|
| Rate for Payer: Quartz Beloit One Network |
$1,167.67
|
| Rate for Payer: Quartz Commercial |
$1,429.80
|
| Rate for Payer: WEA Trust Commercial |
$1,310.65
|
| Rate for Payer: WPS Commercial |
$1,765.09
|
|
|
TIGHTROPE ABS 8 X 12MM BUTTON AR-1588TB
|
Facility
|
OP
|
$2,403.00
|
|
| Hospital Charge Code |
5349048
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$672.84 |
| Max. Negotiated Rate |
$9,612.00 |
| Rate for Payer: Aetna Commercial |
$2,162.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,066.58
|
| Rate for Payer: Aetna Managed Medicare |
$672.84
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,561.95
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,201.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,153.44
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,273.59
|
| Rate for Payer: Cash Price |
$720.90
|
| Rate for Payer: Cigna Commercial |
$2,210.76
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,344.72
|
| Rate for Payer: Health EOS Commercial |
$2,138.67
|
| Rate for Payer: HFN Commercial |
$2,210.76
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,802.25
|
| Rate for Payer: Multiplan Commercial |
$1,922.40
|
| Rate for Payer: NAPHCARE Commercial |
$1,441.80
|
| Rate for Payer: Preferred Network Access Commercial |
$2,210.76
|
| Rate for Payer: Quartz Beloit One Network |
$1,177.47
|
| Rate for Payer: Quartz Commercial |
$1,561.95
|
| Rate for Payer: Quartz Medicare Advantage |
$1,441.80
|
| Rate for Payer: The Alliance Commercial |
$9,612.00
|
| Rate for Payer: WEA Trust Commercial |
$1,321.65
|
| Rate for Payer: WPS Commercial |
$1,779.90
|
|
|
TIGHTROPE ABS 8 X 12MM BUTTON AR-1588TB
|
Facility
|
IP
|
$2,403.00
|
|
| Hospital Charge Code |
5349048
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,177.47 |
| Max. Negotiated Rate |
$2,210.76 |
| Rate for Payer: Aetna Commercial |
$2,162.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,066.58
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,273.59
|
| Rate for Payer: Cash Price |
$720.90
|
| Rate for Payer: Cigna Commercial |
$2,210.76
|
| Rate for Payer: Health EOS Commercial |
$2,138.67
|
| Rate for Payer: HFN Commercial |
$2,210.76
|
| Rate for Payer: Multiplan Commercial |
$1,922.40
|
| Rate for Payer: NAPHCARE Commercial |
$1,441.80
|
| Rate for Payer: Preferred Network Access Commercial |
$2,210.76
|
| Rate for Payer: Quartz Beloit One Network |
$1,177.47
|
| Rate for Payer: Quartz Commercial |
$1,441.80
|
| Rate for Payer: WEA Trust Commercial |
$1,321.65
|
| Rate for Payer: WPS Commercial |
$1,779.90
|
|
|
TIGHTROPE ABS IMPLANT WITH FIBERTAG AR-1588TNT
|
Facility
|
IP
|
$3,564.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
5563608
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,746.36 |
| Max. Negotiated Rate |
$3,278.88 |
| Rate for Payer: Aetna Commercial |
$3,207.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,065.04
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,888.92
|
| Rate for Payer: Cash Price |
$1,069.20
|
| Rate for Payer: Cigna Commercial |
$3,278.88
|
| Rate for Payer: Health EOS Commercial |
$3,171.96
|
| Rate for Payer: HFN Commercial |
$3,278.88
|
| Rate for Payer: Multiplan Commercial |
$2,851.20
|
| Rate for Payer: NAPHCARE Commercial |
$2,138.40
|
| Rate for Payer: Preferred Network Access Commercial |
$3,278.88
|
| Rate for Payer: Quartz Beloit One Network |
$1,746.36
|
| Rate for Payer: Quartz Commercial |
$2,138.40
|
| Rate for Payer: WEA Trust Commercial |
$1,960.20
|
| Rate for Payer: WPS Commercial |
$2,639.85
|
|
|
TIGHTROPE ABS IMPLANT WITH FIBERTAG AR-1588TNT
|
Facility
|
OP
|
$3,564.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
5563608
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$997.92 |
| Max. Negotiated Rate |
$14,256.00 |
| Rate for Payer: Aetna Commercial |
$3,207.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,065.04
|
| Rate for Payer: Aetna Managed Medicare |
$997.92
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,316.60
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,782.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,710.72
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,888.92
|
| Rate for Payer: Cash Price |
$1,069.20
|
| Rate for Payer: Cigna Commercial |
$3,278.88
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,994.41
|
| Rate for Payer: Health EOS Commercial |
$3,171.96
|
| Rate for Payer: HFN Commercial |
$3,278.88
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,673.00
|
| Rate for Payer: Multiplan Commercial |
$2,851.20
|
| Rate for Payer: NAPHCARE Commercial |
$2,138.40
|
| Rate for Payer: Preferred Network Access Commercial |
$3,278.88
|
| Rate for Payer: Quartz Beloit One Network |
$1,746.36
|
| Rate for Payer: Quartz Commercial |
$2,316.60
|
| Rate for Payer: Quartz Medicare Advantage |
$2,138.40
|
| Rate for Payer: The Alliance Commercial |
$14,256.00
|
| Rate for Payer: WEA Trust Commercial |
$1,960.20
|
| Rate for Payer: WPS Commercial |
$2,639.85
|
|
|
TIGHTROPE ACL REPAIR WITH INTERNALBRACE AR-1588R-IB
|
Facility
|
OP
|
$4,804.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
6220127
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,345.12 |
| Max. Negotiated Rate |
$19,216.00 |
| Rate for Payer: Aetna Commercial |
$4,323.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,131.44
|
| Rate for Payer: Aetna Managed Medicare |
$1,345.12
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,122.60
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,402.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,305.92
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,546.12
|
| Rate for Payer: Cash Price |
$1,441.20
|
| Rate for Payer: Cigna Commercial |
$4,419.68
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,688.32
|
| Rate for Payer: Health EOS Commercial |
$4,275.56
|
| Rate for Payer: HFN Commercial |
$4,419.68
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,603.00
|
| Rate for Payer: Multiplan Commercial |
$3,843.20
|
| Rate for Payer: NAPHCARE Commercial |
$2,882.40
|
| Rate for Payer: Preferred Network Access Commercial |
$4,419.68
|
| Rate for Payer: Quartz Beloit One Network |
$2,353.96
|
| Rate for Payer: Quartz Commercial |
$3,122.60
|
| Rate for Payer: Quartz Medicare Advantage |
$2,882.40
|
| Rate for Payer: The Alliance Commercial |
$19,216.00
|
| Rate for Payer: WEA Trust Commercial |
$2,642.20
|
| Rate for Payer: WPS Commercial |
$3,558.32
|
|
|
TIGHTROPE ACL REPAIR WITH INTERNALBRACE AR-1588R-IB
|
Facility
|
IP
|
$4,804.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
6220127
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,353.96 |
| Max. Negotiated Rate |
$4,419.68 |
| Rate for Payer: Aetna Commercial |
$4,323.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,131.44
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,546.12
|
| Rate for Payer: Cash Price |
$1,441.20
|
| Rate for Payer: Cigna Commercial |
$4,419.68
|
| Rate for Payer: Health EOS Commercial |
$4,275.56
|
| Rate for Payer: HFN Commercial |
$4,419.68
|
| Rate for Payer: Multiplan Commercial |
$3,843.20
|
| Rate for Payer: NAPHCARE Commercial |
$2,882.40
|
| Rate for Payer: Preferred Network Access Commercial |
$4,419.68
|
| Rate for Payer: Quartz Beloit One Network |
$2,353.96
|
| Rate for Payer: Quartz Commercial |
$2,882.40
|
| Rate for Payer: WEA Trust Commercial |
$2,642.20
|
| Rate for Payer: WPS Commercial |
$3,558.32
|
|
|
TIGHTROPE BTB AR-1588BTB
|
Facility
|
IP
|
$5,775.00
|
|
| Hospital Charge Code |
3901344
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$2,829.75 |
| Max. Negotiated Rate |
$5,313.00 |
| Rate for Payer: Aetna Commercial |
$5,197.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,966.50
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,060.75
|
| Rate for Payer: Cash Price |
$1,732.50
|
| Rate for Payer: Cigna Commercial |
$5,313.00
|
| Rate for Payer: Health EOS Commercial |
$5,139.75
|
| Rate for Payer: HFN Commercial |
$5,313.00
|
| Rate for Payer: Multiplan Commercial |
$4,620.00
|
| Rate for Payer: NAPHCARE Commercial |
$3,465.00
|
| Rate for Payer: Preferred Network Access Commercial |
$5,313.00
|
| Rate for Payer: Quartz Beloit One Network |
$2,829.75
|
| Rate for Payer: Quartz Commercial |
$3,465.00
|
| Rate for Payer: WEA Trust Commercial |
$3,176.25
|
| Rate for Payer: WPS Commercial |
$4,277.54
|
|
|
TIGHTROPE BTB AR-1588BTB
|
Facility
|
OP
|
$5,775.00
|
|
| Hospital Charge Code |
3901344
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,617.00 |
| Max. Negotiated Rate |
$23,100.00 |
| Rate for Payer: Aetna Commercial |
$5,197.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,966.50
|
| Rate for Payer: Aetna Managed Medicare |
$1,617.00
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,753.75
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,887.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,772.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,060.75
|
| Rate for Payer: Cash Price |
$1,732.50
|
| Rate for Payer: Cigna Commercial |
$5,313.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,231.69
|
| Rate for Payer: Health EOS Commercial |
$5,139.75
|
| Rate for Payer: HFN Commercial |
$5,313.00
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,331.25
|
| Rate for Payer: Multiplan Commercial |
$4,620.00
|
| Rate for Payer: NAPHCARE Commercial |
$3,465.00
|
| Rate for Payer: Preferred Network Access Commercial |
$5,313.00
|
| Rate for Payer: Quartz Beloit One Network |
$2,829.75
|
| Rate for Payer: Quartz Commercial |
$3,753.75
|
| Rate for Payer: Quartz Medicare Advantage |
$3,465.00
|
| Rate for Payer: The Alliance Commercial |
$23,100.00
|
| Rate for Payer: WEA Trust Commercial |
$3,176.25
|
| Rate for Payer: WPS Commercial |
$4,277.54
|
|
