|
TIGHTROPE BTB WITH DEPLOYING SUTURE AR-1588BTB-J
|
Facility
|
OP
|
$5,320.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
5520870
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,489.60 |
| Max. Negotiated Rate |
$21,280.00 |
| Rate for Payer: Aetna Commercial |
$4,788.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,575.20
|
| Rate for Payer: Aetna Managed Medicare |
$1,489.60
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,458.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,660.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,553.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,819.60
|
| Rate for Payer: Cash Price |
$1,596.00
|
| Rate for Payer: Cigna Commercial |
$4,894.40
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,977.07
|
| Rate for Payer: Health EOS Commercial |
$4,734.80
|
| Rate for Payer: HFN Commercial |
$4,894.40
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,990.00
|
| Rate for Payer: Multiplan Commercial |
$4,256.00
|
| Rate for Payer: NAPHCARE Commercial |
$3,192.00
|
| Rate for Payer: Preferred Network Access Commercial |
$4,894.40
|
| Rate for Payer: Quartz Beloit One Network |
$2,606.80
|
| Rate for Payer: Quartz Commercial |
$3,458.00
|
| Rate for Payer: Quartz Medicare Advantage |
$3,192.00
|
| Rate for Payer: The Alliance Commercial |
$21,280.00
|
| Rate for Payer: WEA Trust Commercial |
$2,926.00
|
| Rate for Payer: WPS Commercial |
$3,940.52
|
|
|
TIGHTROPE BTB WITH DEPLOYING SUTURE AR-1588BTB-J
|
Facility
|
IP
|
$5,320.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
5520870
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,606.80 |
| Max. Negotiated Rate |
$4,894.40 |
| Rate for Payer: Aetna Commercial |
$4,788.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,575.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,819.60
|
| Rate for Payer: Cash Price |
$1,596.00
|
| Rate for Payer: Cigna Commercial |
$4,894.40
|
| Rate for Payer: Health EOS Commercial |
$4,734.80
|
| Rate for Payer: HFN Commercial |
$4,894.40
|
| Rate for Payer: Multiplan Commercial |
$4,256.00
|
| Rate for Payer: NAPHCARE Commercial |
$3,192.00
|
| Rate for Payer: Preferred Network Access Commercial |
$4,894.40
|
| Rate for Payer: Quartz Beloit One Network |
$2,606.80
|
| Rate for Payer: Quartz Commercial |
$3,192.00
|
| Rate for Payer: WEA Trust Commercial |
$2,926.00
|
| Rate for Payer: WPS Commercial |
$3,940.52
|
|
|
TIGHTROPE II ABS IMPLANT AR-1588TN/AR-1588TN-20
|
Facility
|
OP
|
$2,449.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
5307003
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$685.72 |
| Max. Negotiated Rate |
$9,796.00 |
| Rate for Payer: Aetna Commercial |
$2,204.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,106.14
|
| Rate for Payer: Aetna Managed Medicare |
$685.72
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,591.85
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,224.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,175.52
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,297.97
|
| Rate for Payer: Cash Price |
$734.70
|
| Rate for Payer: Cigna Commercial |
$2,253.08
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,370.46
|
| Rate for Payer: Health EOS Commercial |
$2,179.61
|
| Rate for Payer: HFN Commercial |
$2,253.08
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,836.75
|
| Rate for Payer: Multiplan Commercial |
$1,959.20
|
| Rate for Payer: NAPHCARE Commercial |
$1,469.40
|
| Rate for Payer: Preferred Network Access Commercial |
$2,253.08
|
| Rate for Payer: Quartz Beloit One Network |
$1,200.01
|
| Rate for Payer: Quartz Commercial |
$1,591.85
|
| Rate for Payer: Quartz Medicare Advantage |
$1,469.40
|
| Rate for Payer: The Alliance Commercial |
$9,796.00
|
| Rate for Payer: WEA Trust Commercial |
$1,346.95
|
| Rate for Payer: WPS Commercial |
$1,813.97
|
|
|
TIGHTROPE II ABS IMPLANT AR-1588TN/AR-1588TN-20
|
Facility
|
IP
|
$2,449.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
5307003
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,200.01 |
| Max. Negotiated Rate |
$2,253.08 |
| Rate for Payer: Aetna Commercial |
$2,204.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,106.14
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,297.97
|
| Rate for Payer: Cash Price |
$734.70
|
| Rate for Payer: Cigna Commercial |
$2,253.08
|
| Rate for Payer: Health EOS Commercial |
$2,179.61
|
| Rate for Payer: HFN Commercial |
$2,253.08
|
| Rate for Payer: Multiplan Commercial |
$1,959.20
|
| Rate for Payer: NAPHCARE Commercial |
$1,469.40
|
| Rate for Payer: Preferred Network Access Commercial |
$2,253.08
|
| Rate for Payer: Quartz Beloit One Network |
$1,200.01
|
| Rate for Payer: Quartz Commercial |
$1,469.40
|
| Rate for Payer: WEA Trust Commercial |
$1,346.95
|
| Rate for Payer: WPS Commercial |
$1,813.97
|
|
|
TIGHTROPE II ABS IMPLANT OPEN AR-1588TN-1/AR-1588TN-21
|
Facility
|
OP
|
$2,583.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
5349049
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$723.24 |
| Max. Negotiated Rate |
$10,332.00 |
| Rate for Payer: Aetna Commercial |
$2,324.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,221.38
|
| Rate for Payer: Aetna Managed Medicare |
$723.24
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,678.95
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,291.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,239.84
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,368.99
|
| Rate for Payer: Cash Price |
$774.90
|
| Rate for Payer: Cigna Commercial |
$2,376.36
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,445.45
|
| Rate for Payer: Health EOS Commercial |
$2,298.87
|
| Rate for Payer: HFN Commercial |
$2,376.36
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,937.25
|
| Rate for Payer: Multiplan Commercial |
$2,066.40
|
| Rate for Payer: NAPHCARE Commercial |
$1,549.80
|
| Rate for Payer: Preferred Network Access Commercial |
$2,376.36
|
| Rate for Payer: Quartz Beloit One Network |
$1,265.67
|
| Rate for Payer: Quartz Commercial |
$1,678.95
|
| Rate for Payer: Quartz Medicare Advantage |
$1,549.80
|
| Rate for Payer: The Alliance Commercial |
$10,332.00
|
| Rate for Payer: WEA Trust Commercial |
$1,420.65
|
| Rate for Payer: WPS Commercial |
$1,913.23
|
|
|
TIGHTROPE II ABS IMPLANT OPEN AR-1588TN-1/AR-1588TN-21
|
Facility
|
IP
|
$2,583.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
5349049
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,265.67 |
| Max. Negotiated Rate |
$2,376.36 |
| Rate for Payer: Aetna Commercial |
$2,324.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,221.38
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,368.99
|
| Rate for Payer: Cash Price |
$774.90
|
| Rate for Payer: Cigna Commercial |
$2,376.36
|
| Rate for Payer: Health EOS Commercial |
$2,298.87
|
| Rate for Payer: HFN Commercial |
$2,376.36
|
| Rate for Payer: Multiplan Commercial |
$2,066.40
|
| Rate for Payer: NAPHCARE Commercial |
$1,549.80
|
| Rate for Payer: Preferred Network Access Commercial |
$2,376.36
|
| Rate for Payer: Quartz Beloit One Network |
$1,265.67
|
| Rate for Payer: Quartz Commercial |
$1,549.80
|
| Rate for Payer: WEA Trust Commercial |
$1,420.65
|
| Rate for Payer: WPS Commercial |
$1,913.23
|
|
|
TIGHTROPE II BTB WITH INTERNALBRACE LIGAMENT AUGMENTATION IBAR AR-1588BTB-IB
|
Facility
|
OP
|
$4,757.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
5993634
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,331.96 |
| Max. Negotiated Rate |
$19,028.00 |
| Rate for Payer: Aetna Commercial |
$4,281.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,091.02
|
| Rate for Payer: Aetna Managed Medicare |
$1,331.96
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,092.05
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,378.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,283.36
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,521.21
|
| Rate for Payer: Cash Price |
$1,427.10
|
| Rate for Payer: Cigna Commercial |
$4,376.44
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,662.02
|
| Rate for Payer: Health EOS Commercial |
$4,233.73
|
| Rate for Payer: HFN Commercial |
$4,376.44
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,567.75
|
| Rate for Payer: Multiplan Commercial |
$3,805.60
|
| Rate for Payer: NAPHCARE Commercial |
$2,854.20
|
| Rate for Payer: Preferred Network Access Commercial |
$4,376.44
|
| Rate for Payer: Quartz Beloit One Network |
$2,330.93
|
| Rate for Payer: Quartz Commercial |
$3,092.05
|
| Rate for Payer: Quartz Medicare Advantage |
$2,854.20
|
| Rate for Payer: The Alliance Commercial |
$19,028.00
|
| Rate for Payer: WEA Trust Commercial |
$2,616.35
|
| Rate for Payer: WPS Commercial |
$3,523.51
|
|
|
TIGHTROPE II BTB WITH INTERNALBRACE LIGAMENT AUGMENTATION IBAR AR-1588BTB-IB
|
Facility
|
IP
|
$4,757.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
5993634
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$2,330.93 |
| Max. Negotiated Rate |
$4,376.44 |
| Rate for Payer: Aetna Commercial |
$4,281.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,091.02
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,521.21
|
| Rate for Payer: Cash Price |
$1,427.10
|
| Rate for Payer: Cigna Commercial |
$4,376.44
|
| Rate for Payer: Health EOS Commercial |
$4,233.73
|
| Rate for Payer: HFN Commercial |
$4,376.44
|
| Rate for Payer: Multiplan Commercial |
$3,805.60
|
| Rate for Payer: NAPHCARE Commercial |
$2,854.20
|
| Rate for Payer: Preferred Network Access Commercial |
$4,376.44
|
| Rate for Payer: Quartz Beloit One Network |
$2,330.93
|
| Rate for Payer: Quartz Commercial |
$2,854.20
|
| Rate for Payer: WEA Trust Commercial |
$2,616.35
|
| Rate for Payer: WPS Commercial |
$3,523.51
|
|
|
TIGHTROPE II RT ACL WITH DEPLOYING SUTURE IBAR AR-1588RT-J/AR-1588RT-IB
|
Facility
|
OP
|
$3,936.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
5520871
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,102.08 |
| Max. Negotiated Rate |
$15,744.00 |
| Rate for Payer: Aetna Commercial |
$3,542.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,384.96
|
| Rate for Payer: Aetna Managed Medicare |
$1,102.08
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,558.40
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,968.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,889.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,086.08
|
| Rate for Payer: Cash Price |
$1,180.80
|
| Rate for Payer: Cigna Commercial |
$3,621.12
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,202.59
|
| Rate for Payer: Health EOS Commercial |
$3,503.04
|
| Rate for Payer: HFN Commercial |
$3,621.12
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,952.00
|
| Rate for Payer: Multiplan Commercial |
$3,148.80
|
| Rate for Payer: NAPHCARE Commercial |
$2,361.60
|
| Rate for Payer: Preferred Network Access Commercial |
$3,621.12
|
| Rate for Payer: Quartz Beloit One Network |
$1,928.64
|
| Rate for Payer: Quartz Commercial |
$2,558.40
|
| Rate for Payer: Quartz Medicare Advantage |
$2,361.60
|
| Rate for Payer: The Alliance Commercial |
$15,744.00
|
| Rate for Payer: WEA Trust Commercial |
$2,164.80
|
| Rate for Payer: WPS Commercial |
$2,915.40
|
|
|
TIGHTROPE II RT ACL WITH DEPLOYING SUTURE IBAR AR-1588RT-J/AR-1588RT-IB
|
Facility
|
IP
|
$3,936.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
5520871
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,928.64 |
| Max. Negotiated Rate |
$3,621.12 |
| Rate for Payer: Aetna Commercial |
$3,542.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,384.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,086.08
|
| Rate for Payer: Cash Price |
$1,180.80
|
| Rate for Payer: Cigna Commercial |
$3,621.12
|
| Rate for Payer: Health EOS Commercial |
$3,503.04
|
| Rate for Payer: HFN Commercial |
$3,621.12
|
| Rate for Payer: Multiplan Commercial |
$3,148.80
|
| Rate for Payer: NAPHCARE Commercial |
$2,361.60
|
| Rate for Payer: Preferred Network Access Commercial |
$3,621.12
|
| Rate for Payer: Quartz Beloit One Network |
$1,928.64
|
| Rate for Payer: Quartz Commercial |
$2,361.60
|
| Rate for Payer: WEA Trust Commercial |
$2,164.80
|
| Rate for Payer: WPS Commercial |
$2,915.40
|
|
|
TIGHTROPE MINI IMPLANT SYS 1.1MM AR-8919DS
|
Facility
|
OP
|
$6,804.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
5178859
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,905.12 |
| Max. Negotiated Rate |
$27,216.00 |
| Rate for Payer: Aetna Commercial |
$6,123.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,851.44
|
| Rate for Payer: Aetna Managed Medicare |
$1,905.12
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,422.60
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,402.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,265.92
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,606.12
|
| Rate for Payer: Cash Price |
$2,041.20
|
| Rate for Payer: Cigna Commercial |
$6,259.68
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,807.52
|
| Rate for Payer: Health EOS Commercial |
$6,055.56
|
| Rate for Payer: HFN Commercial |
$6,259.68
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5,103.00
|
| Rate for Payer: Multiplan Commercial |
$5,443.20
|
| Rate for Payer: NAPHCARE Commercial |
$4,082.40
|
| Rate for Payer: Preferred Network Access Commercial |
$6,259.68
|
| Rate for Payer: Quartz Beloit One Network |
$3,333.96
|
| Rate for Payer: Quartz Commercial |
$4,422.60
|
| Rate for Payer: Quartz Medicare Advantage |
$4,082.40
|
| Rate for Payer: The Alliance Commercial |
$27,216.00
|
| Rate for Payer: WEA Trust Commercial |
$3,742.20
|
| Rate for Payer: WPS Commercial |
$5,039.72
|
|
|
TIGHTROPE MINI IMPLANT SYS 1.1MM AR-8919DS
|
Facility
|
IP
|
$6,804.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
5178859
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,333.96 |
| Max. Negotiated Rate |
$6,259.68 |
| Rate for Payer: Aetna Commercial |
$6,123.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,851.44
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,606.12
|
| Rate for Payer: Cash Price |
$2,041.20
|
| Rate for Payer: Cigna Commercial |
$6,259.68
|
| Rate for Payer: Health EOS Commercial |
$6,055.56
|
| Rate for Payer: HFN Commercial |
$6,259.68
|
| Rate for Payer: Multiplan Commercial |
$5,443.20
|
| Rate for Payer: NAPHCARE Commercial |
$4,082.40
|
| Rate for Payer: Preferred Network Access Commercial |
$6,259.68
|
| Rate for Payer: Quartz Beloit One Network |
$3,333.96
|
| Rate for Payer: Quartz Commercial |
$4,082.40
|
| Rate for Payer: WEA Trust Commercial |
$3,742.20
|
| Rate for Payer: WPS Commercial |
$5,039.72
|
|
|
TIGHTROPE RT ACL AR-1588RTT
|
Facility
|
IP
|
$4,750.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
4519923
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,327.50 |
| Max. Negotiated Rate |
$4,370.00 |
| Rate for Payer: Aetna Commercial |
$4,275.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,085.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,517.50
|
| Rate for Payer: Cash Price |
$1,425.00
|
| Rate for Payer: Cigna Commercial |
$4,370.00
|
| Rate for Payer: Health EOS Commercial |
$4,227.50
|
| Rate for Payer: HFN Commercial |
$4,370.00
|
| Rate for Payer: Multiplan Commercial |
$3,800.00
|
| Rate for Payer: NAPHCARE Commercial |
$2,850.00
|
| Rate for Payer: Preferred Network Access Commercial |
$4,370.00
|
| Rate for Payer: Quartz Beloit One Network |
$2,327.50
|
| Rate for Payer: Quartz Commercial |
$2,850.00
|
| Rate for Payer: WEA Trust Commercial |
$2,612.50
|
| Rate for Payer: WPS Commercial |
$3,518.32
|
|
|
TIGHTROPE RT ACL AR-1588RTT
|
Facility
|
OP
|
$4,750.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
4519923
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,330.00 |
| Max. Negotiated Rate |
$19,000.00 |
| Rate for Payer: Aetna Commercial |
$4,275.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,085.00
|
| Rate for Payer: Aetna Managed Medicare |
$1,330.00
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,087.50
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,375.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,280.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,517.50
|
| Rate for Payer: Cash Price |
$1,425.00
|
| Rate for Payer: Cigna Commercial |
$4,370.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,658.10
|
| Rate for Payer: Health EOS Commercial |
$4,227.50
|
| Rate for Payer: HFN Commercial |
$4,370.00
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,562.50
|
| Rate for Payer: Multiplan Commercial |
$3,800.00
|
| Rate for Payer: NAPHCARE Commercial |
$2,850.00
|
| Rate for Payer: Preferred Network Access Commercial |
$4,370.00
|
| Rate for Payer: Quartz Beloit One Network |
$2,327.50
|
| Rate for Payer: Quartz Commercial |
$3,087.50
|
| Rate for Payer: Quartz Medicare Advantage |
$2,850.00
|
| Rate for Payer: The Alliance Commercial |
$19,000.00
|
| Rate for Payer: WEA Trust Commercial |
$2,612.50
|
| Rate for Payer: WPS Commercial |
$3,518.32
|
|
|
Tilt Table Test
|
Facility
|
IP
|
$2,256.00
|
|
|
Service Code
|
CPT 93660
|
| Hospital Charge Code |
3052519
|
|
Hospital Revenue Code
|
481
|
| Min. Negotiated Rate |
$1,105.44 |
| Max. Negotiated Rate |
$2,075.52 |
| Rate for Payer: Aetna Commercial |
$2,030.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,940.16
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,195.68
|
| Rate for Payer: Cash Price |
$676.80
|
| Rate for Payer: Cigna Commercial |
$2,075.52
|
| Rate for Payer: Health EOS Commercial |
$2,007.84
|
| Rate for Payer: HFN Commercial |
$2,075.52
|
| Rate for Payer: Multiplan Commercial |
$1,804.80
|
| Rate for Payer: NAPHCARE Commercial |
$1,353.60
|
| Rate for Payer: Preferred Network Access Commercial |
$2,075.52
|
| Rate for Payer: Quartz Beloit One Network |
$1,105.44
|
| Rate for Payer: Quartz Commercial |
$1,353.60
|
| Rate for Payer: WEA Trust Commercial |
$1,240.80
|
| Rate for Payer: WPS Commercial |
$1,671.02
|
|
|
Tilt Table Test
|
Facility
|
OP
|
$2,256.00
|
|
|
Service Code
|
CPT 93660
|
| Hospital Charge Code |
3052519
|
|
Hospital Revenue Code
|
481
|
| Min. Negotiated Rate |
$529.77 |
| Max. Negotiated Rate |
$2,119.08 |
| Rate for Payer: Aetna Commercial |
$2,030.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,940.16
|
| Rate for Payer: Aetna Managed Medicare |
$529.77
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,466.40
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,128.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,082.88
|
| Rate for Payer: Anthem Medicare Advantage |
$529.77
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,195.68
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$529.77
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$529.77
|
| Rate for Payer: Cash Price |
$676.80
|
| Rate for Payer: Cash Price |
$676.80
|
| Rate for Payer: Cigna Commercial |
$2,075.52
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$529.77
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,262.46
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$529.77
|
| Rate for Payer: Health EOS Commercial |
$2,007.84
|
| Rate for Payer: HFN Commercial |
$2,075.52
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,970.74
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$529.77
|
| Rate for Payer: Independent Care Health Plan Medicare |
$529.77
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$529.77
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$529.77
|
| Rate for Payer: Multiplan Commercial |
$1,804.80
|
| Rate for Payer: NAPHCARE Commercial |
$794.66
|
| Rate for Payer: Preferred Network Access Commercial |
$2,075.52
|
| Rate for Payer: Quartz Beloit One Network |
$1,105.44
|
| Rate for Payer: Quartz Commercial |
$1,466.40
|
| Rate for Payer: Quartz Medicare Advantage |
$529.77
|
| Rate for Payer: The Alliance Commercial |
$2,119.08
|
| Rate for Payer: United Healthcare Medicare Advantage |
$529.77
|
| Rate for Payer: WEA Trust Commercial |
$1,240.80
|
| Rate for Payer: Wellcare Medicare |
$529.77
|
| Rate for Payer: WPS Commercial |
$1,671.02
|
|
|
Timolol 0.5% Ophth Solution 5ml [Med]
|
Facility
|
OP
|
$35.00
|
|
| Hospital Charge Code |
2974988
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.80 |
| Max. Negotiated Rate |
$140.00 |
| Rate for Payer: Aetna Commercial |
$31.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$30.10
|
| Rate for Payer: Aetna Managed Medicare |
$9.80
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$22.75
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$17.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$16.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$18.55
|
| Rate for Payer: Cash Price |
$10.50
|
| Rate for Payer: Cigna Commercial |
$32.20
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$19.59
|
| Rate for Payer: Health EOS Commercial |
$31.15
|
| Rate for Payer: HFN Commercial |
$32.20
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$26.25
|
| Rate for Payer: Multiplan Commercial |
$28.00
|
| Rate for Payer: NAPHCARE Commercial |
$21.00
|
| Rate for Payer: Preferred Network Access Commercial |
$32.20
|
| Rate for Payer: Quartz Beloit One Network |
$17.15
|
| Rate for Payer: Quartz Commercial |
$22.75
|
| Rate for Payer: Quartz Medicare Advantage |
$21.00
|
| Rate for Payer: The Alliance Commercial |
$140.00
|
| Rate for Payer: WEA Trust Commercial |
$19.25
|
| Rate for Payer: WPS Commercial |
$25.92
|
|
|
Timolol 0.5% Ophth Solution 5ml [Med]
|
Facility
|
IP
|
$35.00
|
|
| Hospital Charge Code |
2974988
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$17.15 |
| Max. Negotiated Rate |
$32.20 |
| Rate for Payer: Aetna Commercial |
$31.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$30.10
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$18.55
|
| Rate for Payer: Cash Price |
$10.50
|
| Rate for Payer: Cigna Commercial |
$32.20
|
| Rate for Payer: Health EOS Commercial |
$31.15
|
| Rate for Payer: HFN Commercial |
$32.20
|
| Rate for Payer: Multiplan Commercial |
$28.00
|
| Rate for Payer: NAPHCARE Commercial |
$21.00
|
| Rate for Payer: Preferred Network Access Commercial |
$32.20
|
| Rate for Payer: Quartz Beloit One Network |
$17.15
|
| Rate for Payer: Quartz Commercial |
$21.00
|
| Rate for Payer: WEA Trust Commercial |
$19.25
|
| Rate for Payer: WPS Commercial |
$25.92
|
|
|
TIP 0.9MM 30DEG KELMAN PHACO 8065750263
|
Facility
|
OP
|
$1,190.00
|
|
| Hospital Charge Code |
2964181
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$333.20 |
| Max. Negotiated Rate |
$4,760.00 |
| Rate for Payer: Aetna Commercial |
$1,071.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,023.40
|
| Rate for Payer: Aetna Managed Medicare |
$333.20
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$773.50
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$595.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$571.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$630.70
|
| Rate for Payer: Cash Price |
$357.00
|
| Rate for Payer: Cigna Commercial |
$1,094.80
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$665.92
|
| Rate for Payer: Health EOS Commercial |
$1,059.10
|
| Rate for Payer: HFN Commercial |
$1,094.80
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$892.50
|
| Rate for Payer: Multiplan Commercial |
$952.00
|
| Rate for Payer: NAPHCARE Commercial |
$714.00
|
| Rate for Payer: Preferred Network Access Commercial |
$1,094.80
|
| Rate for Payer: Quartz Beloit One Network |
$583.10
|
| Rate for Payer: Quartz Commercial |
$773.50
|
| Rate for Payer: Quartz Medicare Advantage |
$714.00
|
| Rate for Payer: The Alliance Commercial |
$4,760.00
|
| Rate for Payer: WEA Trust Commercial |
$654.50
|
| Rate for Payer: WPS Commercial |
$881.43
|
|
|
TIP 0.9MM 30DEG KELMAN PHACO 8065750263
|
Facility
|
IP
|
$1,190.00
|
|
| Hospital Charge Code |
2964181
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$583.10 |
| Max. Negotiated Rate |
$1,094.80 |
| Rate for Payer: Aetna Commercial |
$1,071.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,023.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$630.70
|
| Rate for Payer: Cash Price |
$357.00
|
| Rate for Payer: Cigna Commercial |
$1,094.80
|
| Rate for Payer: Health EOS Commercial |
$1,059.10
|
| Rate for Payer: HFN Commercial |
$1,094.80
|
| Rate for Payer: Multiplan Commercial |
$952.00
|
| Rate for Payer: NAPHCARE Commercial |
$714.00
|
| Rate for Payer: Preferred Network Access Commercial |
$1,094.80
|
| Rate for Payer: Quartz Beloit One Network |
$583.10
|
| Rate for Payer: Quartz Commercial |
$714.00
|
| Rate for Payer: WEA Trust Commercial |
$654.50
|
| Rate for Payer: WPS Commercial |
$881.43
|
|
|
TIP FAN SPRAY CO-AXIAL INTERPULSE 0210-18-200***DISC 7/5/17
|
Facility
|
OP
|
$561.00
|
|
| Hospital Charge Code |
2963188
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$157.08 |
| Max. Negotiated Rate |
$2,244.00 |
| Rate for Payer: Aetna Commercial |
$504.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$482.46
|
| Rate for Payer: Aetna Managed Medicare |
$157.08
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$364.65
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$280.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$269.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$297.33
|
| Rate for Payer: Cash Price |
$168.30
|
| Rate for Payer: Cigna Commercial |
$516.12
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$313.94
|
| Rate for Payer: Health EOS Commercial |
$499.29
|
| Rate for Payer: HFN Commercial |
$516.12
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$420.75
|
| Rate for Payer: Multiplan Commercial |
$448.80
|
| Rate for Payer: NAPHCARE Commercial |
$336.60
|
| Rate for Payer: Preferred Network Access Commercial |
$516.12
|
| Rate for Payer: Quartz Beloit One Network |
$274.89
|
| Rate for Payer: Quartz Commercial |
$364.65
|
| Rate for Payer: Quartz Medicare Advantage |
$336.60
|
| Rate for Payer: The Alliance Commercial |
$2,244.00
|
| Rate for Payer: WEA Trust Commercial |
$308.55
|
| Rate for Payer: WPS Commercial |
$415.53
|
|
|
TIP FAN SPRAY CO-AXIAL INTERPULSE 0210-18-200***DISC 7/5/17
|
Facility
|
IP
|
$561.00
|
|
| Hospital Charge Code |
2963188
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$274.89 |
| Max. Negotiated Rate |
$516.12 |
| Rate for Payer: Aetna Commercial |
$504.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$482.46
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$297.33
|
| Rate for Payer: Cash Price |
$168.30
|
| Rate for Payer: Cigna Commercial |
$516.12
|
| Rate for Payer: Health EOS Commercial |
$499.29
|
| Rate for Payer: HFN Commercial |
$516.12
|
| Rate for Payer: Multiplan Commercial |
$448.80
|
| Rate for Payer: NAPHCARE Commercial |
$336.60
|
| Rate for Payer: Preferred Network Access Commercial |
$516.12
|
| Rate for Payer: Quartz Beloit One Network |
$274.89
|
| Rate for Payer: Quartz Commercial |
$336.60
|
| Rate for Payer: WEA Trust Commercial |
$308.55
|
| Rate for Payer: WPS Commercial |
$415.53
|
|
|
TIP HARMONIC 5MM LAP ACE363
|
Facility
|
OP
|
$5,621.00
|
|
| Hospital Charge Code |
3072548
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,573.88 |
| Max. Negotiated Rate |
$22,484.00 |
| Rate for Payer: Aetna Commercial |
$5,058.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,834.06
|
| Rate for Payer: Aetna Managed Medicare |
$1,573.88
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,653.65
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,810.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,698.08
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,979.13
|
| Rate for Payer: Cash Price |
$1,686.30
|
| Rate for Payer: Cigna Commercial |
$5,171.32
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,145.51
|
| Rate for Payer: Health EOS Commercial |
$5,002.69
|
| Rate for Payer: HFN Commercial |
$5,171.32
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,215.75
|
| Rate for Payer: Multiplan Commercial |
$4,496.80
|
| Rate for Payer: NAPHCARE Commercial |
$3,372.60
|
| Rate for Payer: Preferred Network Access Commercial |
$5,171.32
|
| Rate for Payer: Quartz Beloit One Network |
$2,754.29
|
| Rate for Payer: Quartz Commercial |
$3,653.65
|
| Rate for Payer: Quartz Medicare Advantage |
$3,372.60
|
| Rate for Payer: The Alliance Commercial |
$22,484.00
|
| Rate for Payer: WEA Trust Commercial |
$3,091.55
|
| Rate for Payer: WPS Commercial |
$4,163.47
|
|
|
TIP HARMONIC 5MM LAP ACE363
|
Facility
|
IP
|
$5,621.00
|
|
| Hospital Charge Code |
3072548
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$2,754.29 |
| Max. Negotiated Rate |
$5,171.32 |
| Rate for Payer: Aetna Commercial |
$5,058.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,834.06
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,979.13
|
| Rate for Payer: Cash Price |
$1,686.30
|
| Rate for Payer: Cigna Commercial |
$5,171.32
|
| Rate for Payer: Health EOS Commercial |
$5,002.69
|
| Rate for Payer: HFN Commercial |
$5,171.32
|
| Rate for Payer: Multiplan Commercial |
$4,496.80
|
| Rate for Payer: NAPHCARE Commercial |
$3,372.60
|
| Rate for Payer: Preferred Network Access Commercial |
$5,171.32
|
| Rate for Payer: Quartz Beloit One Network |
$2,754.29
|
| Rate for Payer: Quartz Commercial |
$3,372.60
|
| Rate for Payer: WEA Trust Commercial |
$3,091.55
|
| Rate for Payer: WPS Commercial |
$4,163.47
|
|
|
TIP HARMONIC FOCUS HAR9F
|
Facility
|
IP
|
$5,988.00
|
|
| Hospital Charge Code |
3116531
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$2,934.12 |
| Max. Negotiated Rate |
$5,508.96 |
| Rate for Payer: Aetna Commercial |
$5,389.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,149.68
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,173.64
|
| Rate for Payer: Cash Price |
$1,796.40
|
| Rate for Payer: Cigna Commercial |
$5,508.96
|
| Rate for Payer: Health EOS Commercial |
$5,329.32
|
| Rate for Payer: HFN Commercial |
$5,508.96
|
| Rate for Payer: Multiplan Commercial |
$4,790.40
|
| Rate for Payer: NAPHCARE Commercial |
$3,592.80
|
| Rate for Payer: Preferred Network Access Commercial |
$5,508.96
|
| Rate for Payer: Quartz Beloit One Network |
$2,934.12
|
| Rate for Payer: Quartz Commercial |
$3,592.80
|
| Rate for Payer: WEA Trust Commercial |
$3,293.40
|
| Rate for Payer: WPS Commercial |
$4,435.31
|
|
