|
F/G SHM 2.4/4/120-0/16MM M0063801070
|
Facility
|
IP
|
$2,660.00
|
|
| Hospital Charge Code |
4520072
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,355.54 |
| Max. Negotiated Rate |
$2,545.09 |
| Rate for Payer: Aetna Commercial |
$2,489.76
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,379.10
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,466.19
|
| Rate for Payer: Cash Price |
$798.00
|
| Rate for Payer: Cigna Commercial |
$2,545.09
|
| Rate for Payer: Health EOS Commercial |
$2,462.10
|
| Rate for Payer: HFN Commercial |
$2,545.09
|
| Rate for Payer: Multiplan Commercial |
$2,213.12
|
| Rate for Payer: Preferred Network Access Commercial |
$2,545.09
|
| Rate for Payer: Quartz Beloit One Network |
$1,355.54
|
| Rate for Payer: Quartz Commercial |
$1,659.84
|
| Rate for Payer: WEA Trust Commercial |
$1,521.52
|
| Rate for Payer: WPS Commercial |
$2,049.00
|
|
|
FIBER 273 HOLMIUM LASER G48522
|
Facility
|
OP
|
$5,836.00
|
|
| Hospital Charge Code |
2964977
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,699.44 |
| Max. Negotiated Rate |
$5,583.88 |
| Rate for Payer: Aetna Commercial |
$5,462.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,219.72
|
| Rate for Payer: Aetna Managed Medicare |
$1,699.44
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,945.14
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,034.72
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,913.33
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,216.80
|
| Rate for Payer: Cash Price |
$1,750.80
|
| Rate for Payer: Cigna Commercial |
$5,583.88
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,396.55
|
| Rate for Payer: Health EOS Commercial |
$5,401.80
|
| Rate for Payer: HFN Commercial |
$5,583.88
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,552.08
|
| Rate for Payer: Multiplan Commercial |
$4,855.55
|
| Rate for Payer: NAPHCARE Commercial |
$3,641.66
|
| Rate for Payer: Preferred Network Access Commercial |
$5,583.88
|
| Rate for Payer: Quartz Beloit One Network |
$2,974.03
|
| Rate for Payer: Quartz Commercial |
$3,945.14
|
| Rate for Payer: Quartz Medicare Advantage |
$3,641.66
|
| Rate for Payer: The Alliance Commercial |
$3,034.72
|
| Rate for Payer: WEA Trust Commercial |
$3,338.19
|
| Rate for Payer: WPS Commercial |
$4,495.47
|
|
|
FIBER 273 HOLMIUM LASER G48522
|
Facility
|
IP
|
$5,836.00
|
|
| Hospital Charge Code |
2964977
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$2,974.03 |
| Max. Negotiated Rate |
$5,583.88 |
| Rate for Payer: Aetna Commercial |
$5,462.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,219.72
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,216.80
|
| Rate for Payer: Cash Price |
$1,750.80
|
| Rate for Payer: Cigna Commercial |
$5,583.88
|
| Rate for Payer: Health EOS Commercial |
$5,401.80
|
| Rate for Payer: HFN Commercial |
$5,583.88
|
| Rate for Payer: Multiplan Commercial |
$4,855.55
|
| Rate for Payer: Preferred Network Access Commercial |
$5,583.88
|
| Rate for Payer: Quartz Beloit One Network |
$2,974.03
|
| Rate for Payer: Quartz Commercial |
$3,641.66
|
| Rate for Payer: WEA Trust Commercial |
$3,338.19
|
| Rate for Payer: WPS Commercial |
$4,495.47
|
|
|
FIBERLINK #2 FIBERWIRE AR-7235
|
Facility
|
IP
|
$915.00
|
|
| Hospital Charge Code |
2964681
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$466.28 |
| Max. Negotiated Rate |
$875.47 |
| Rate for Payer: Aetna Commercial |
$856.44
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$818.38
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$504.35
|
| Rate for Payer: Cash Price |
$274.50
|
| Rate for Payer: Cigna Commercial |
$875.47
|
| Rate for Payer: Health EOS Commercial |
$846.92
|
| Rate for Payer: HFN Commercial |
$875.47
|
| Rate for Payer: Multiplan Commercial |
$761.28
|
| Rate for Payer: Preferred Network Access Commercial |
$875.47
|
| Rate for Payer: Quartz Beloit One Network |
$466.28
|
| Rate for Payer: Quartz Commercial |
$570.96
|
| Rate for Payer: WEA Trust Commercial |
$523.38
|
| Rate for Payer: WPS Commercial |
$704.82
|
|
|
FIBERLINK #2 FIBERWIRE AR-7235
|
Facility
|
OP
|
$915.00
|
|
| Hospital Charge Code |
2964681
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$266.45 |
| Max. Negotiated Rate |
$875.47 |
| Rate for Payer: Aetna Commercial |
$856.44
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$818.38
|
| Rate for Payer: Aetna Managed Medicare |
$266.45
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$618.54
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$475.80
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$456.77
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$504.35
|
| Rate for Payer: Cash Price |
$274.50
|
| Rate for Payer: Cigna Commercial |
$875.47
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$532.53
|
| Rate for Payer: Health EOS Commercial |
$846.92
|
| Rate for Payer: HFN Commercial |
$875.47
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$713.70
|
| Rate for Payer: Multiplan Commercial |
$761.28
|
| Rate for Payer: NAPHCARE Commercial |
$570.96
|
| Rate for Payer: Preferred Network Access Commercial |
$875.47
|
| Rate for Payer: Quartz Beloit One Network |
$466.28
|
| Rate for Payer: Quartz Commercial |
$618.54
|
| Rate for Payer: Quartz Medicare Advantage |
$570.96
|
| Rate for Payer: The Alliance Commercial |
$475.80
|
| Rate for Payer: WEA Trust Commercial |
$523.38
|
| Rate for Payer: WPS Commercial |
$704.82
|
|
|
FIBER OPTIC GREENLIGHT MoXy 0010-2400
|
Facility
|
IP
|
$6,455.00
|
|
| Hospital Charge Code |
5307001
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$3,289.47 |
| Max. Negotiated Rate |
$6,176.14 |
| Rate for Payer: Aetna Commercial |
$6,041.88
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,773.35
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,558.00
|
| Rate for Payer: Cash Price |
$1,936.50
|
| Rate for Payer: Cigna Commercial |
$6,176.14
|
| Rate for Payer: Health EOS Commercial |
$5,974.75
|
| Rate for Payer: HFN Commercial |
$6,176.14
|
| Rate for Payer: Multiplan Commercial |
$5,370.56
|
| Rate for Payer: Preferred Network Access Commercial |
$6,176.14
|
| Rate for Payer: Quartz Beloit One Network |
$3,289.47
|
| Rate for Payer: Quartz Commercial |
$4,027.92
|
| Rate for Payer: WEA Trust Commercial |
$3,692.26
|
| Rate for Payer: WPS Commercial |
$4,972.29
|
|
|
FIBER OPTIC GREENLIGHT MoXy 0010-2400
|
Facility
|
OP
|
$6,455.00
|
|
| Hospital Charge Code |
5307001
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,879.70 |
| Max. Negotiated Rate |
$6,176.14 |
| Rate for Payer: Aetna Commercial |
$6,041.88
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,773.35
|
| Rate for Payer: Aetna Managed Medicare |
$1,879.70
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,363.58
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,356.60
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,222.34
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,558.00
|
| Rate for Payer: Cash Price |
$1,936.50
|
| Rate for Payer: Cigna Commercial |
$6,176.14
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,756.81
|
| Rate for Payer: Health EOS Commercial |
$5,974.75
|
| Rate for Payer: HFN Commercial |
$6,176.14
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5,034.90
|
| Rate for Payer: Multiplan Commercial |
$5,370.56
|
| Rate for Payer: NAPHCARE Commercial |
$4,027.92
|
| Rate for Payer: Preferred Network Access Commercial |
$6,176.14
|
| Rate for Payer: Quartz Beloit One Network |
$3,289.47
|
| Rate for Payer: Quartz Commercial |
$4,363.58
|
| Rate for Payer: Quartz Medicare Advantage |
$4,027.92
|
| Rate for Payer: The Alliance Commercial |
$3,356.60
|
| Rate for Payer: WEA Trust Commercial |
$3,692.26
|
| Rate for Payer: WPS Commercial |
$4,972.29
|
|
|
FIBERRING WITH SHUTTLE LOOP 25MM (12PK) AR-7282-25
|
Facility
|
IP
|
$1,802.00
|
|
| Hospital Charge Code |
6220126
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$918.30 |
| Max. Negotiated Rate |
$1,724.15 |
| Rate for Payer: Aetna Commercial |
$1,686.67
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,611.71
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$993.26
|
| Rate for Payer: Cash Price |
$540.60
|
| Rate for Payer: Cigna Commercial |
$1,724.15
|
| Rate for Payer: Health EOS Commercial |
$1,667.93
|
| Rate for Payer: HFN Commercial |
$1,724.15
|
| Rate for Payer: Multiplan Commercial |
$1,499.26
|
| Rate for Payer: Preferred Network Access Commercial |
$1,724.15
|
| Rate for Payer: Quartz Beloit One Network |
$918.30
|
| Rate for Payer: Quartz Commercial |
$1,124.45
|
| Rate for Payer: WEA Trust Commercial |
$1,030.74
|
| Rate for Payer: WPS Commercial |
$1,388.08
|
|
|
FIBERRING WITH SHUTTLE LOOP 25MM (12PK) AR-7282-25
|
Facility
|
OP
|
$1,802.00
|
|
| Hospital Charge Code |
6220126
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$524.74 |
| Max. Negotiated Rate |
$1,724.15 |
| Rate for Payer: Aetna Commercial |
$1,686.67
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,611.71
|
| Rate for Payer: Aetna Managed Medicare |
$524.74
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,218.15
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$937.04
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$899.56
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$993.26
|
| Rate for Payer: Cash Price |
$540.60
|
| Rate for Payer: Cigna Commercial |
$1,724.15
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,048.76
|
| Rate for Payer: Health EOS Commercial |
$1,667.93
|
| Rate for Payer: HFN Commercial |
$1,724.15
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,405.56
|
| Rate for Payer: Multiplan Commercial |
$1,499.26
|
| Rate for Payer: NAPHCARE Commercial |
$1,124.45
|
| Rate for Payer: Preferred Network Access Commercial |
$1,724.15
|
| Rate for Payer: Quartz Beloit One Network |
$918.30
|
| Rate for Payer: Quartz Commercial |
$1,218.15
|
| Rate for Payer: Quartz Medicare Advantage |
$1,124.45
|
| Rate for Payer: The Alliance Commercial |
$937.04
|
| Rate for Payer: WEA Trust Commercial |
$1,030.74
|
| Rate for Payer: WPS Commercial |
$1,388.08
|
|
|
FIBERSTICK / FIBERWIRE 2-0 AR-7222
|
Facility
|
OP
|
$784.00
|
|
| Hospital Charge Code |
5563233
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$228.30 |
| Max. Negotiated Rate |
$750.13 |
| Rate for Payer: Aetna Commercial |
$733.82
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$701.21
|
| Rate for Payer: Aetna Managed Medicare |
$228.30
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$529.98
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$407.68
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$391.37
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$432.14
|
| Rate for Payer: Cash Price |
$235.20
|
| Rate for Payer: Cigna Commercial |
$750.13
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$456.29
|
| Rate for Payer: Health EOS Commercial |
$725.67
|
| Rate for Payer: HFN Commercial |
$750.13
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$611.52
|
| Rate for Payer: Multiplan Commercial |
$652.29
|
| Rate for Payer: NAPHCARE Commercial |
$489.22
|
| Rate for Payer: Preferred Network Access Commercial |
$750.13
|
| Rate for Payer: Quartz Beloit One Network |
$399.53
|
| Rate for Payer: Quartz Commercial |
$529.98
|
| Rate for Payer: Quartz Medicare Advantage |
$489.22
|
| Rate for Payer: The Alliance Commercial |
$407.68
|
| Rate for Payer: WEA Trust Commercial |
$448.45
|
| Rate for Payer: WPS Commercial |
$603.92
|
|
|
FIBERSTICK / FIBERWIRE 2-0 AR-7222
|
Facility
|
IP
|
$784.00
|
|
| Hospital Charge Code |
5563233
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$399.53 |
| Max. Negotiated Rate |
$750.13 |
| Rate for Payer: Aetna Commercial |
$733.82
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$701.21
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$432.14
|
| Rate for Payer: Cash Price |
$235.20
|
| Rate for Payer: Cigna Commercial |
$750.13
|
| Rate for Payer: Health EOS Commercial |
$725.67
|
| Rate for Payer: HFN Commercial |
$750.13
|
| Rate for Payer: Multiplan Commercial |
$652.29
|
| Rate for Payer: Preferred Network Access Commercial |
$750.13
|
| Rate for Payer: Quartz Beloit One Network |
$399.53
|
| Rate for Payer: Quartz Commercial |
$489.22
|
| Rate for Payer: WEA Trust Commercial |
$448.45
|
| Rate for Payer: WPS Commercial |
$603.92
|
|
|
FIBERSTITCH 1.5 CURVED 12 DEG AR-4580
|
Facility
|
IP
|
$3,751.01
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
6246203
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,911.51 |
| Max. Negotiated Rate |
$3,588.97 |
| Rate for Payer: Aetna Commercial |
$3,510.95
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,354.90
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,067.56
|
| Rate for Payer: Cash Price |
$1,125.30
|
| Rate for Payer: Cigna Commercial |
$3,588.97
|
| Rate for Payer: Health EOS Commercial |
$3,471.93
|
| Rate for Payer: HFN Commercial |
$3,588.97
|
| Rate for Payer: Multiplan Commercial |
$3,120.84
|
| Rate for Payer: Preferred Network Access Commercial |
$3,588.97
|
| Rate for Payer: Quartz Beloit One Network |
$1,911.51
|
| Rate for Payer: Quartz Commercial |
$2,340.63
|
| Rate for Payer: WEA Trust Commercial |
$2,145.58
|
| Rate for Payer: WPS Commercial |
$2,889.40
|
|
|
FIBERSTITCH 1.5 CURVED 12 DEG AR-4580
|
Facility
|
OP
|
$3,751.01
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
6246203
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,092.29 |
| Max. Negotiated Rate |
$3,588.97 |
| Rate for Payer: Aetna Commercial |
$3,510.95
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,354.90
|
| Rate for Payer: Aetna Managed Medicare |
$1,092.29
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,535.68
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,950.53
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,872.50
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,067.56
|
| Rate for Payer: Cash Price |
$1,125.30
|
| Rate for Payer: Cigna Commercial |
$3,588.97
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,183.09
|
| Rate for Payer: Health EOS Commercial |
$3,471.93
|
| Rate for Payer: HFN Commercial |
$3,588.97
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,925.79
|
| Rate for Payer: Multiplan Commercial |
$3,120.84
|
| Rate for Payer: NAPHCARE Commercial |
$2,340.63
|
| Rate for Payer: Preferred Network Access Commercial |
$3,588.97
|
| Rate for Payer: Quartz Beloit One Network |
$1,911.51
|
| Rate for Payer: Quartz Commercial |
$2,535.68
|
| Rate for Payer: Quartz Medicare Advantage |
$2,340.63
|
| Rate for Payer: The Alliance Commercial |
$1,950.53
|
| Rate for Payer: WEA Trust Commercial |
$2,145.58
|
| Rate for Payer: WPS Commercial |
$2,889.40
|
|
|
FIBERSTITCH 1.5 CURVED 24 DEG AR-4580-24
|
Facility
|
IP
|
$3,751.01
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
6246204
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,911.51 |
| Max. Negotiated Rate |
$3,588.97 |
| Rate for Payer: Aetna Commercial |
$3,510.95
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,354.90
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,067.56
|
| Rate for Payer: Cash Price |
$1,125.30
|
| Rate for Payer: Cigna Commercial |
$3,588.97
|
| Rate for Payer: Health EOS Commercial |
$3,471.93
|
| Rate for Payer: HFN Commercial |
$3,588.97
|
| Rate for Payer: Multiplan Commercial |
$3,120.84
|
| Rate for Payer: Preferred Network Access Commercial |
$3,588.97
|
| Rate for Payer: Quartz Beloit One Network |
$1,911.51
|
| Rate for Payer: Quartz Commercial |
$2,340.63
|
| Rate for Payer: WEA Trust Commercial |
$2,145.58
|
| Rate for Payer: WPS Commercial |
$2,889.40
|
|
|
FIBERSTITCH 1.5 CURVED 24 DEG AR-4580-24
|
Facility
|
OP
|
$3,751.01
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
6246204
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,092.29 |
| Max. Negotiated Rate |
$3,588.97 |
| Rate for Payer: Aetna Commercial |
$3,510.95
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,354.90
|
| Rate for Payer: Aetna Managed Medicare |
$1,092.29
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,535.68
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,950.53
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,872.50
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,067.56
|
| Rate for Payer: Cash Price |
$1,125.30
|
| Rate for Payer: Cigna Commercial |
$3,588.97
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,183.09
|
| Rate for Payer: Health EOS Commercial |
$3,471.93
|
| Rate for Payer: HFN Commercial |
$3,588.97
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,925.79
|
| Rate for Payer: Multiplan Commercial |
$3,120.84
|
| Rate for Payer: NAPHCARE Commercial |
$2,340.63
|
| Rate for Payer: Preferred Network Access Commercial |
$3,588.97
|
| Rate for Payer: Quartz Beloit One Network |
$1,911.51
|
| Rate for Payer: Quartz Commercial |
$2,535.68
|
| Rate for Payer: Quartz Medicare Advantage |
$2,340.63
|
| Rate for Payer: The Alliance Commercial |
$1,950.53
|
| Rate for Payer: WEA Trust Commercial |
$2,145.58
|
| Rate for Payer: WPS Commercial |
$2,889.40
|
|
|
FIBERSTITCH IMPLANT CURVED 12 DEG AR-4570
|
Facility
|
OP
|
$5,266.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
5563292
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,533.46 |
| Max. Negotiated Rate |
$5,038.51 |
| Rate for Payer: Aetna Commercial |
$4,928.98
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,709.91
|
| Rate for Payer: Aetna Managed Medicare |
$1,533.46
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,559.82
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,738.32
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,628.79
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,902.62
|
| Rate for Payer: Cash Price |
$1,579.80
|
| Rate for Payer: Cigna Commercial |
$5,038.51
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,064.81
|
| Rate for Payer: Health EOS Commercial |
$4,874.21
|
| Rate for Payer: HFN Commercial |
$5,038.51
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,107.48
|
| Rate for Payer: Multiplan Commercial |
$4,381.31
|
| Rate for Payer: NAPHCARE Commercial |
$3,285.98
|
| Rate for Payer: Preferred Network Access Commercial |
$5,038.51
|
| Rate for Payer: Quartz Beloit One Network |
$2,683.55
|
| Rate for Payer: Quartz Commercial |
$3,559.82
|
| Rate for Payer: Quartz Medicare Advantage |
$3,285.98
|
| Rate for Payer: The Alliance Commercial |
$2,738.32
|
| Rate for Payer: WEA Trust Commercial |
$3,012.15
|
| Rate for Payer: WPS Commercial |
$4,056.40
|
|
|
FIBERSTITCH IMPLANT CURVED 12 DEG AR-4570
|
Facility
|
IP
|
$5,266.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
5563292
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,683.55 |
| Max. Negotiated Rate |
$5,038.51 |
| Rate for Payer: Aetna Commercial |
$4,928.98
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,709.91
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,902.62
|
| Rate for Payer: Cash Price |
$1,579.80
|
| Rate for Payer: Cigna Commercial |
$5,038.51
|
| Rate for Payer: Health EOS Commercial |
$4,874.21
|
| Rate for Payer: HFN Commercial |
$5,038.51
|
| Rate for Payer: Multiplan Commercial |
$4,381.31
|
| Rate for Payer: Preferred Network Access Commercial |
$5,038.51
|
| Rate for Payer: Quartz Beloit One Network |
$2,683.55
|
| Rate for Payer: Quartz Commercial |
$3,285.98
|
| Rate for Payer: WEA Trust Commercial |
$3,012.15
|
| Rate for Payer: WPS Commercial |
$4,056.40
|
|
|
FIBERSTITCH IMPLANT CURVED 24 DEG AR-4570-24
|
Facility
|
IP
|
$5,266.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
5767727
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,683.55 |
| Max. Negotiated Rate |
$5,038.51 |
| Rate for Payer: Aetna Commercial |
$4,928.98
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,709.91
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,902.62
|
| Rate for Payer: Cash Price |
$1,579.80
|
| Rate for Payer: Cigna Commercial |
$5,038.51
|
| Rate for Payer: Health EOS Commercial |
$4,874.21
|
| Rate for Payer: HFN Commercial |
$5,038.51
|
| Rate for Payer: Multiplan Commercial |
$4,381.31
|
| Rate for Payer: Preferred Network Access Commercial |
$5,038.51
|
| Rate for Payer: Quartz Beloit One Network |
$2,683.55
|
| Rate for Payer: Quartz Commercial |
$3,285.98
|
| Rate for Payer: WEA Trust Commercial |
$3,012.15
|
| Rate for Payer: WPS Commercial |
$4,056.40
|
|
|
FIBERSTITCH IMPLANT CURVED 24 DEG AR-4570-24
|
Facility
|
OP
|
$5,266.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
5767727
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,533.46 |
| Max. Negotiated Rate |
$5,038.51 |
| Rate for Payer: Aetna Commercial |
$4,928.98
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,709.91
|
| Rate for Payer: Aetna Managed Medicare |
$1,533.46
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,559.82
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,738.32
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,628.79
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,902.62
|
| Rate for Payer: Cash Price |
$1,579.80
|
| Rate for Payer: Cigna Commercial |
$5,038.51
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,064.81
|
| Rate for Payer: Health EOS Commercial |
$4,874.21
|
| Rate for Payer: HFN Commercial |
$5,038.51
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,107.48
|
| Rate for Payer: Multiplan Commercial |
$4,381.31
|
| Rate for Payer: NAPHCARE Commercial |
$3,285.98
|
| Rate for Payer: Preferred Network Access Commercial |
$5,038.51
|
| Rate for Payer: Quartz Beloit One Network |
$2,683.55
|
| Rate for Payer: Quartz Commercial |
$3,559.82
|
| Rate for Payer: Quartz Medicare Advantage |
$3,285.98
|
| Rate for Payer: The Alliance Commercial |
$2,738.32
|
| Rate for Payer: WEA Trust Commercial |
$3,012.15
|
| Rate for Payer: WPS Commercial |
$4,056.40
|
|
|
FIBERSTITCH IMPLANT CURVED RC AR-19032C
|
Facility
|
OP
|
$3,751.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
6246220
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,092.29 |
| Max. Negotiated Rate |
$3,588.96 |
| Rate for Payer: Aetna Commercial |
$3,510.94
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,354.89
|
| Rate for Payer: Aetna Managed Medicare |
$1,092.29
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,535.68
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,950.52
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,872.50
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,067.55
|
| Rate for Payer: Cash Price |
$1,125.30
|
| Rate for Payer: Cigna Commercial |
$3,588.96
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,183.08
|
| Rate for Payer: Health EOS Commercial |
$3,471.93
|
| Rate for Payer: HFN Commercial |
$3,588.96
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,925.78
|
| Rate for Payer: Multiplan Commercial |
$3,120.83
|
| Rate for Payer: NAPHCARE Commercial |
$2,340.62
|
| Rate for Payer: Preferred Network Access Commercial |
$3,588.96
|
| Rate for Payer: Quartz Beloit One Network |
$1,911.51
|
| Rate for Payer: Quartz Commercial |
$2,535.68
|
| Rate for Payer: Quartz Medicare Advantage |
$2,340.62
|
| Rate for Payer: The Alliance Commercial |
$1,950.52
|
| Rate for Payer: WEA Trust Commercial |
$2,145.57
|
| Rate for Payer: WPS Commercial |
$2,889.40
|
|
|
FIBERSTITCH IMPLANT CURVED RC AR-19032C
|
Facility
|
IP
|
$3,751.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
6246220
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,911.51 |
| Max. Negotiated Rate |
$3,588.96 |
| Rate for Payer: Aetna Commercial |
$3,510.94
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,354.89
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,067.55
|
| Rate for Payer: Cash Price |
$1,125.30
|
| Rate for Payer: Cigna Commercial |
$3,588.96
|
| Rate for Payer: Health EOS Commercial |
$3,471.93
|
| Rate for Payer: HFN Commercial |
$3,588.96
|
| Rate for Payer: Multiplan Commercial |
$3,120.83
|
| Rate for Payer: Preferred Network Access Commercial |
$3,588.96
|
| Rate for Payer: Quartz Beloit One Network |
$1,911.51
|
| Rate for Payer: Quartz Commercial |
$2,340.62
|
| Rate for Payer: WEA Trust Commercial |
$2,145.57
|
| Rate for Payer: WPS Commercial |
$2,889.40
|
|
|
FIBERSTITCH IMPLANT, REVERSE CURVED AR-4570R
|
Facility
|
OP
|
$5,063.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
5685819
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,474.35 |
| Max. Negotiated Rate |
$4,844.28 |
| Rate for Payer: Aetna Commercial |
$4,738.97
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,528.35
|
| Rate for Payer: Aetna Managed Medicare |
$1,474.35
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,422.59
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,632.76
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,527.45
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,790.73
|
| Rate for Payer: Cash Price |
$1,518.90
|
| Rate for Payer: Cigna Commercial |
$4,844.28
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,946.67
|
| Rate for Payer: Health EOS Commercial |
$4,686.31
|
| Rate for Payer: HFN Commercial |
$4,844.28
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,949.14
|
| Rate for Payer: Multiplan Commercial |
$4,212.42
|
| Rate for Payer: NAPHCARE Commercial |
$3,159.31
|
| Rate for Payer: Preferred Network Access Commercial |
$4,844.28
|
| Rate for Payer: Quartz Beloit One Network |
$2,580.10
|
| Rate for Payer: Quartz Commercial |
$3,422.59
|
| Rate for Payer: Quartz Medicare Advantage |
$3,159.31
|
| Rate for Payer: The Alliance Commercial |
$2,632.76
|
| Rate for Payer: WEA Trust Commercial |
$2,896.04
|
| Rate for Payer: WPS Commercial |
$3,900.03
|
|
|
FIBERSTITCH IMPLANT, REVERSE CURVED AR-4570R
|
Facility
|
IP
|
$5,063.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
5685819
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,580.10 |
| Max. Negotiated Rate |
$4,844.28 |
| Rate for Payer: Aetna Commercial |
$4,738.97
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,528.35
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,790.73
|
| Rate for Payer: Cash Price |
$1,518.90
|
| Rate for Payer: Cigna Commercial |
$4,844.28
|
| Rate for Payer: Health EOS Commercial |
$4,686.31
|
| Rate for Payer: HFN Commercial |
$4,844.28
|
| Rate for Payer: Multiplan Commercial |
$4,212.42
|
| Rate for Payer: Preferred Network Access Commercial |
$4,844.28
|
| Rate for Payer: Quartz Beloit One Network |
$2,580.10
|
| Rate for Payer: Quartz Commercial |
$3,159.31
|
| Rate for Payer: WEA Trust Commercial |
$2,896.04
|
| Rate for Payer: WPS Commercial |
$3,900.03
|
|
|
FIBERSTITCH IMPLANT STRAIGHT AR-4570S
|
Facility
|
OP
|
$5,266.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
5767728
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,533.46 |
| Max. Negotiated Rate |
$5,038.51 |
| Rate for Payer: Aetna Commercial |
$4,928.98
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,709.91
|
| Rate for Payer: Aetna Managed Medicare |
$1,533.46
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,559.82
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,738.32
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,628.79
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,902.62
|
| Rate for Payer: Cash Price |
$1,579.80
|
| Rate for Payer: Cigna Commercial |
$5,038.51
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,064.81
|
| Rate for Payer: Health EOS Commercial |
$4,874.21
|
| Rate for Payer: HFN Commercial |
$5,038.51
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,107.48
|
| Rate for Payer: Multiplan Commercial |
$4,381.31
|
| Rate for Payer: NAPHCARE Commercial |
$3,285.98
|
| Rate for Payer: Preferred Network Access Commercial |
$5,038.51
|
| Rate for Payer: Quartz Beloit One Network |
$2,683.55
|
| Rate for Payer: Quartz Commercial |
$3,559.82
|
| Rate for Payer: Quartz Medicare Advantage |
$3,285.98
|
| Rate for Payer: The Alliance Commercial |
$2,738.32
|
| Rate for Payer: WEA Trust Commercial |
$3,012.15
|
| Rate for Payer: WPS Commercial |
$4,056.40
|
|
|
FIBERSTITCH IMPLANT STRAIGHT AR-4570S
|
Facility
|
IP
|
$5,266.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
5767728
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,683.55 |
| Max. Negotiated Rate |
$5,038.51 |
| Rate for Payer: Aetna Commercial |
$4,928.98
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,709.91
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,902.62
|
| Rate for Payer: Cash Price |
$1,579.80
|
| Rate for Payer: Cigna Commercial |
$5,038.51
|
| Rate for Payer: Health EOS Commercial |
$4,874.21
|
| Rate for Payer: HFN Commercial |
$5,038.51
|
| Rate for Payer: Multiplan Commercial |
$4,381.31
|
| Rate for Payer: Preferred Network Access Commercial |
$5,038.51
|
| Rate for Payer: Quartz Beloit One Network |
$2,683.55
|
| Rate for Payer: Quartz Commercial |
$3,285.98
|
| Rate for Payer: WEA Trust Commercial |
$3,012.15
|
| Rate for Payer: WPS Commercial |
$4,056.40
|
|
