|
LASER, ENDOLUMENAL VENOUS WITH ULTRASOUND
|
Facility
|
OP
|
$3,935.00
|
|
| Hospital Charge Code |
2960197
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,101.80 |
| Max. Negotiated Rate |
$15,740.00 |
| Rate for Payer: Aetna Commercial |
$3,541.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,384.10
|
| Rate for Payer: Aetna Managed Medicare |
$1,101.80
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,557.75
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,967.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,888.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,085.55
|
| Rate for Payer: Cash Price |
$1,180.50
|
| Rate for Payer: Cigna Commercial |
$3,620.20
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,202.03
|
| Rate for Payer: Health EOS Commercial |
$3,502.15
|
| Rate for Payer: HFN Commercial |
$3,620.20
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,951.25
|
| Rate for Payer: Multiplan Commercial |
$3,148.00
|
| Rate for Payer: NAPHCARE Commercial |
$2,361.00
|
| Rate for Payer: Preferred Network Access Commercial |
$3,620.20
|
| Rate for Payer: Quartz Beloit One Network |
$1,928.15
|
| Rate for Payer: Quartz Commercial |
$2,557.75
|
| Rate for Payer: Quartz Medicare Advantage |
$2,361.00
|
| Rate for Payer: The Alliance Commercial |
$15,740.00
|
| Rate for Payer: WEA Trust Commercial |
$2,164.25
|
| Rate for Payer: WPS Commercial |
$2,914.65
|
|
|
LASER, ENDOSCOPIC CYCLOPHOTOCOAGULATION
|
Facility
|
IP
|
$7,644.00
|
|
| Hospital Charge Code |
6222300
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$3,745.56 |
| Max. Negotiated Rate |
$7,032.48 |
| Rate for Payer: Aetna Commercial |
$6,879.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,573.84
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,051.32
|
| Rate for Payer: Cash Price |
$2,293.20
|
| Rate for Payer: Cigna Commercial |
$7,032.48
|
| Rate for Payer: Health EOS Commercial |
$6,803.16
|
| Rate for Payer: HFN Commercial |
$7,032.48
|
| Rate for Payer: Multiplan Commercial |
$6,115.20
|
| Rate for Payer: NAPHCARE Commercial |
$4,586.40
|
| Rate for Payer: Preferred Network Access Commercial |
$7,032.48
|
| Rate for Payer: Quartz Beloit One Network |
$3,745.56
|
| Rate for Payer: Quartz Commercial |
$4,586.40
|
| Rate for Payer: WEA Trust Commercial |
$4,204.20
|
| Rate for Payer: WPS Commercial |
$5,661.91
|
|
|
LASER, ENDOSCOPIC CYCLOPHOTOCOAGULATION
|
Facility
|
OP
|
$7,644.00
|
|
| Hospital Charge Code |
6222300
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$2,140.32 |
| Max. Negotiated Rate |
$30,576.00 |
| Rate for Payer: Aetna Commercial |
$6,879.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,573.84
|
| Rate for Payer: Aetna Managed Medicare |
$2,140.32
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,968.60
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,822.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,669.12
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,051.32
|
| Rate for Payer: Cash Price |
$2,293.20
|
| Rate for Payer: Cigna Commercial |
$7,032.48
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,277.58
|
| Rate for Payer: Health EOS Commercial |
$6,803.16
|
| Rate for Payer: HFN Commercial |
$7,032.48
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5,733.00
|
| Rate for Payer: Multiplan Commercial |
$6,115.20
|
| Rate for Payer: NAPHCARE Commercial |
$4,586.40
|
| Rate for Payer: Preferred Network Access Commercial |
$7,032.48
|
| Rate for Payer: Quartz Beloit One Network |
$3,745.56
|
| Rate for Payer: Quartz Commercial |
$4,968.60
|
| Rate for Payer: Quartz Medicare Advantage |
$4,586.40
|
| Rate for Payer: The Alliance Commercial |
$30,576.00
|
| Rate for Payer: WEA Trust Commercial |
$4,204.20
|
| Rate for Payer: WPS Commercial |
$5,661.91
|
|
|
LASER FIBER CO2 IMPERIAL 500 CO2-500 10988
|
Facility
|
IP
|
$5,778.00
|
|
| Hospital Charge Code |
6083641
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$2,831.22 |
| Max. Negotiated Rate |
$5,315.76 |
| Rate for Payer: Aetna Commercial |
$5,200.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,969.08
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,062.34
|
| Rate for Payer: Cash Price |
$1,733.40
|
| Rate for Payer: Cigna Commercial |
$5,315.76
|
| Rate for Payer: Health EOS Commercial |
$5,142.42
|
| Rate for Payer: HFN Commercial |
$5,315.76
|
| Rate for Payer: Multiplan Commercial |
$4,622.40
|
| Rate for Payer: NAPHCARE Commercial |
$3,466.80
|
| Rate for Payer: Preferred Network Access Commercial |
$5,315.76
|
| Rate for Payer: Quartz Beloit One Network |
$2,831.22
|
| Rate for Payer: Quartz Commercial |
$3,466.80
|
| Rate for Payer: WEA Trust Commercial |
$3,177.90
|
| Rate for Payer: WPS Commercial |
$4,279.76
|
|
|
LASER FIBER CO2 IMPERIAL 500 CO2-500 10988
|
Facility
|
OP
|
$5,778.00
|
|
| Hospital Charge Code |
6083641
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,617.84 |
| Max. Negotiated Rate |
$23,112.00 |
| Rate for Payer: Aetna Commercial |
$5,200.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,969.08
|
| Rate for Payer: Aetna Managed Medicare |
$1,617.84
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,755.70
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,889.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,773.44
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,062.34
|
| Rate for Payer: Cash Price |
$1,733.40
|
| Rate for Payer: Cigna Commercial |
$5,315.76
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,233.37
|
| Rate for Payer: Health EOS Commercial |
$5,142.42
|
| Rate for Payer: HFN Commercial |
$5,315.76
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,333.50
|
| Rate for Payer: Multiplan Commercial |
$4,622.40
|
| Rate for Payer: NAPHCARE Commercial |
$3,466.80
|
| Rate for Payer: Preferred Network Access Commercial |
$5,315.76
|
| Rate for Payer: Quartz Beloit One Network |
$2,831.22
|
| Rate for Payer: Quartz Commercial |
$3,755.70
|
| Rate for Payer: Quartz Medicare Advantage |
$3,466.80
|
| Rate for Payer: The Alliance Commercial |
$23,112.00
|
| Rate for Payer: WEA Trust Commercial |
$3,177.90
|
| Rate for Payer: WPS Commercial |
$4,279.76
|
|
|
LASER FIBER FLEXIVA 550 MICRON M0068403930/M006L8405930
|
Facility
|
OP
|
$4,941.00
|
|
| Hospital Charge Code |
4595199
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,383.48 |
| Max. Negotiated Rate |
$19,764.00 |
| Rate for Payer: Aetna Commercial |
$4,446.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,249.26
|
| Rate for Payer: Aetna Managed Medicare |
$1,383.48
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,211.65
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,470.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,371.68
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,618.73
|
| Rate for Payer: Cash Price |
$1,482.30
|
| Rate for Payer: Cigna Commercial |
$4,545.72
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,764.98
|
| Rate for Payer: Health EOS Commercial |
$4,397.49
|
| Rate for Payer: HFN Commercial |
$4,545.72
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,705.75
|
| Rate for Payer: Multiplan Commercial |
$3,952.80
|
| Rate for Payer: NAPHCARE Commercial |
$2,964.60
|
| Rate for Payer: Preferred Network Access Commercial |
$4,545.72
|
| Rate for Payer: Quartz Beloit One Network |
$2,421.09
|
| Rate for Payer: Quartz Commercial |
$3,211.65
|
| Rate for Payer: Quartz Medicare Advantage |
$2,964.60
|
| Rate for Payer: The Alliance Commercial |
$19,764.00
|
| Rate for Payer: WEA Trust Commercial |
$2,717.55
|
| Rate for Payer: WPS Commercial |
$3,659.80
|
|
|
LASER FIBER FLEXIVA 550 MICRON M0068403930/M006L8405930
|
Facility
|
IP
|
$4,941.00
|
|
| Hospital Charge Code |
4595199
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$2,421.09 |
| Max. Negotiated Rate |
$4,545.72 |
| Rate for Payer: Aetna Commercial |
$4,446.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,249.26
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,618.73
|
| Rate for Payer: Cash Price |
$1,482.30
|
| Rate for Payer: Cigna Commercial |
$4,545.72
|
| Rate for Payer: Health EOS Commercial |
$4,397.49
|
| Rate for Payer: HFN Commercial |
$4,545.72
|
| Rate for Payer: Multiplan Commercial |
$3,952.80
|
| Rate for Payer: NAPHCARE Commercial |
$2,964.60
|
| Rate for Payer: Preferred Network Access Commercial |
$4,545.72
|
| Rate for Payer: Quartz Beloit One Network |
$2,421.09
|
| Rate for Payer: Quartz Commercial |
$2,964.60
|
| Rate for Payer: WEA Trust Commercial |
$2,717.55
|
| Rate for Payer: WPS Commercial |
$3,659.80
|
|
|
LASER FIBER FLEXIVA PULSE 910 M006L8405940
|
Facility
|
IP
|
$6,220.00
|
|
| Hospital Charge Code |
4595196
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$3,047.80 |
| Max. Negotiated Rate |
$5,722.40 |
| Rate for Payer: Aetna Commercial |
$5,598.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,349.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,296.60
|
| Rate for Payer: Cash Price |
$1,866.00
|
| Rate for Payer: Cigna Commercial |
$5,722.40
|
| Rate for Payer: Health EOS Commercial |
$5,535.80
|
| Rate for Payer: HFN Commercial |
$5,722.40
|
| Rate for Payer: Multiplan Commercial |
$4,976.00
|
| Rate for Payer: NAPHCARE Commercial |
$3,732.00
|
| Rate for Payer: Preferred Network Access Commercial |
$5,722.40
|
| Rate for Payer: Quartz Beloit One Network |
$3,047.80
|
| Rate for Payer: Quartz Commercial |
$3,732.00
|
| Rate for Payer: WEA Trust Commercial |
$3,421.00
|
| Rate for Payer: WPS Commercial |
$4,607.15
|
|
|
LASER FIBER FLEXIVA PULSE 910 M006L8405940
|
Facility
|
OP
|
$6,220.00
|
|
| Hospital Charge Code |
4595196
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,741.60 |
| Max. Negotiated Rate |
$24,880.00 |
| Rate for Payer: Aetna Commercial |
$5,598.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,349.20
|
| Rate for Payer: Aetna Managed Medicare |
$1,741.60
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,043.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,110.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,985.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,296.60
|
| Rate for Payer: Cash Price |
$1,866.00
|
| Rate for Payer: Cigna Commercial |
$5,722.40
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,480.71
|
| Rate for Payer: Health EOS Commercial |
$5,535.80
|
| Rate for Payer: HFN Commercial |
$5,722.40
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,665.00
|
| Rate for Payer: Multiplan Commercial |
$4,976.00
|
| Rate for Payer: NAPHCARE Commercial |
$3,732.00
|
| Rate for Payer: Preferred Network Access Commercial |
$5,722.40
|
| Rate for Payer: Quartz Beloit One Network |
$3,047.80
|
| Rate for Payer: Quartz Commercial |
$4,043.00
|
| Rate for Payer: Quartz Medicare Advantage |
$3,732.00
|
| Rate for Payer: The Alliance Commercial |
$24,880.00
|
| Rate for Payer: WEA Trust Commercial |
$3,421.00
|
| Rate for Payer: WPS Commercial |
$4,607.15
|
|
|
LASER FIBER FLEXIVA TRACTIP 200 MICRON M0068403960/M006L7406960
|
Facility
|
IP
|
$5,442.00
|
|
| Hospital Charge Code |
4595200
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$2,666.58 |
| Max. Negotiated Rate |
$5,006.64 |
| Rate for Payer: Aetna Commercial |
$4,897.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,680.12
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,884.26
|
| Rate for Payer: Cash Price |
$1,632.60
|
| Rate for Payer: Cigna Commercial |
$5,006.64
|
| Rate for Payer: Health EOS Commercial |
$4,843.38
|
| Rate for Payer: HFN Commercial |
$5,006.64
|
| Rate for Payer: Multiplan Commercial |
$4,353.60
|
| Rate for Payer: NAPHCARE Commercial |
$3,265.20
|
| Rate for Payer: Preferred Network Access Commercial |
$5,006.64
|
| Rate for Payer: Quartz Beloit One Network |
$2,666.58
|
| Rate for Payer: Quartz Commercial |
$3,265.20
|
| Rate for Payer: WEA Trust Commercial |
$2,993.10
|
| Rate for Payer: WPS Commercial |
$4,030.89
|
|
|
LASER FIBER FLEXIVA TRACTIP 200 MICRON M0068403960/M006L7406960
|
Facility
|
OP
|
$5,442.00
|
|
| Hospital Charge Code |
4595200
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,523.76 |
| Max. Negotiated Rate |
$21,768.00 |
| Rate for Payer: Aetna Commercial |
$4,897.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,680.12
|
| Rate for Payer: Aetna Managed Medicare |
$1,523.76
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,537.30
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,721.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,612.16
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,884.26
|
| Rate for Payer: Cash Price |
$1,632.60
|
| Rate for Payer: Cigna Commercial |
$5,006.64
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,045.34
|
| Rate for Payer: Health EOS Commercial |
$4,843.38
|
| Rate for Payer: HFN Commercial |
$5,006.64
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,081.50
|
| Rate for Payer: Multiplan Commercial |
$4,353.60
|
| Rate for Payer: NAPHCARE Commercial |
$3,265.20
|
| Rate for Payer: Preferred Network Access Commercial |
$5,006.64
|
| Rate for Payer: Quartz Beloit One Network |
$2,666.58
|
| Rate for Payer: Quartz Commercial |
$3,537.30
|
| Rate for Payer: Quartz Medicare Advantage |
$3,265.20
|
| Rate for Payer: The Alliance Commercial |
$21,768.00
|
| Rate for Payer: WEA Trust Commercial |
$2,993.10
|
| Rate for Payer: WPS Commercial |
$4,030.89
|
|
|
LASER FIBER FORTEC HOLMIUM 365 10494
|
Facility
|
OP
|
$1,920.00
|
|
| Hospital Charge Code |
6174515
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$537.60 |
| Max. Negotiated Rate |
$7,680.00 |
| Rate for Payer: Aetna Commercial |
$1,728.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,651.20
|
| Rate for Payer: Aetna Managed Medicare |
$537.60
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,248.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$960.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$921.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,017.60
|
| Rate for Payer: Cash Price |
$576.00
|
| Rate for Payer: Cigna Commercial |
$1,766.40
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,074.43
|
| Rate for Payer: Health EOS Commercial |
$1,708.80
|
| Rate for Payer: HFN Commercial |
$1,766.40
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,440.00
|
| Rate for Payer: Multiplan Commercial |
$1,536.00
|
| Rate for Payer: NAPHCARE Commercial |
$1,152.00
|
| Rate for Payer: Preferred Network Access Commercial |
$1,766.40
|
| Rate for Payer: Quartz Beloit One Network |
$940.80
|
| Rate for Payer: Quartz Commercial |
$1,248.00
|
| Rate for Payer: Quartz Medicare Advantage |
$1,152.00
|
| Rate for Payer: The Alliance Commercial |
$7,680.00
|
| Rate for Payer: WEA Trust Commercial |
$1,056.00
|
| Rate for Payer: WPS Commercial |
$1,422.14
|
|
|
LASER FIBER FORTEC HOLMIUM 365 10494
|
Facility
|
IP
|
$1,920.00
|
|
| Hospital Charge Code |
6174515
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$940.80 |
| Max. Negotiated Rate |
$1,766.40 |
| Rate for Payer: Aetna Commercial |
$1,728.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,651.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,017.60
|
| Rate for Payer: Cash Price |
$576.00
|
| Rate for Payer: Cigna Commercial |
$1,766.40
|
| Rate for Payer: Health EOS Commercial |
$1,708.80
|
| Rate for Payer: HFN Commercial |
$1,766.40
|
| Rate for Payer: Multiplan Commercial |
$1,536.00
|
| Rate for Payer: NAPHCARE Commercial |
$1,152.00
|
| Rate for Payer: Preferred Network Access Commercial |
$1,766.40
|
| Rate for Payer: Quartz Beloit One Network |
$940.80
|
| Rate for Payer: Quartz Commercial |
$1,152.00
|
| Rate for Payer: WEA Trust Commercial |
$1,056.00
|
| Rate for Payer: WPS Commercial |
$1,422.14
|
|
|
LASER FIBER FORTEC HOLMIUM 550 10495
|
Facility
|
OP
|
$2,095.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
6184978
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$586.60 |
| Max. Negotiated Rate |
$8,380.00 |
| Rate for Payer: Aetna Commercial |
$1,885.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,801.70
|
| Rate for Payer: Aetna Managed Medicare |
$586.60
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,361.75
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,047.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,005.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,110.35
|
| Rate for Payer: Cash Price |
$628.50
|
| Rate for Payer: Cigna Commercial |
$1,927.40
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,172.36
|
| Rate for Payer: Health EOS Commercial |
$1,864.55
|
| Rate for Payer: HFN Commercial |
$1,927.40
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,571.25
|
| Rate for Payer: Multiplan Commercial |
$1,676.00
|
| Rate for Payer: NAPHCARE Commercial |
$1,257.00
|
| Rate for Payer: Preferred Network Access Commercial |
$1,927.40
|
| Rate for Payer: Quartz Beloit One Network |
$1,026.55
|
| Rate for Payer: Quartz Commercial |
$1,361.75
|
| Rate for Payer: Quartz Medicare Advantage |
$1,257.00
|
| Rate for Payer: The Alliance Commercial |
$8,380.00
|
| Rate for Payer: WEA Trust Commercial |
$1,152.25
|
| Rate for Payer: WPS Commercial |
$1,551.77
|
|
|
LASER FIBER FORTEC HOLMIUM 550 10495
|
Facility
|
IP
|
$2,095.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
6184978
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,026.55 |
| Max. Negotiated Rate |
$1,927.40 |
| Rate for Payer: Aetna Commercial |
$1,885.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,801.70
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,110.35
|
| Rate for Payer: Cash Price |
$628.50
|
| Rate for Payer: Cigna Commercial |
$1,927.40
|
| Rate for Payer: Health EOS Commercial |
$1,864.55
|
| Rate for Payer: HFN Commercial |
$1,927.40
|
| Rate for Payer: Multiplan Commercial |
$1,676.00
|
| Rate for Payer: NAPHCARE Commercial |
$1,257.00
|
| Rate for Payer: Preferred Network Access Commercial |
$1,927.40
|
| Rate for Payer: Quartz Beloit One Network |
$1,026.55
|
| Rate for Payer: Quartz Commercial |
$1,257.00
|
| Rate for Payer: WEA Trust Commercial |
$1,152.25
|
| Rate for Payer: WPS Commercial |
$1,551.77
|
|
|
LASER FIBER GREENLIGHT XPS MoXy 10486
|
Facility
|
OP
|
$6,455.00
|
|
| Hospital Charge Code |
5306930
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,807.40 |
| Max. Negotiated Rate |
$25,820.00 |
| Rate for Payer: Aetna Commercial |
$5,809.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,551.30
|
| Rate for Payer: Aetna Managed Medicare |
$1,807.40
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,195.75
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,227.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,098.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,421.15
|
| Rate for Payer: Cash Price |
$1,936.50
|
| Rate for Payer: Cigna Commercial |
$5,938.60
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,612.22
|
| Rate for Payer: Health EOS Commercial |
$5,744.95
|
| Rate for Payer: HFN Commercial |
$5,938.60
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,841.25
|
| Rate for Payer: Multiplan Commercial |
$5,164.00
|
| Rate for Payer: NAPHCARE Commercial |
$3,873.00
|
| Rate for Payer: Preferred Network Access Commercial |
$5,938.60
|
| Rate for Payer: Quartz Beloit One Network |
$3,162.95
|
| Rate for Payer: Quartz Commercial |
$4,195.75
|
| Rate for Payer: Quartz Medicare Advantage |
$3,873.00
|
| Rate for Payer: The Alliance Commercial |
$25,820.00
|
| Rate for Payer: WEA Trust Commercial |
$3,550.25
|
| Rate for Payer: WPS Commercial |
$4,781.22
|
|
|
LASER FIBER GREENLIGHT XPS MoXy 10486
|
Facility
|
IP
|
$6,455.00
|
|
| Hospital Charge Code |
5306930
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$3,162.95 |
| Max. Negotiated Rate |
$5,938.60 |
| Rate for Payer: Aetna Commercial |
$5,809.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,551.30
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,421.15
|
| Rate for Payer: Cash Price |
$1,936.50
|
| Rate for Payer: Cigna Commercial |
$5,938.60
|
| Rate for Payer: Health EOS Commercial |
$5,744.95
|
| Rate for Payer: HFN Commercial |
$5,938.60
|
| Rate for Payer: Multiplan Commercial |
$5,164.00
|
| Rate for Payer: NAPHCARE Commercial |
$3,873.00
|
| Rate for Payer: Preferred Network Access Commercial |
$5,938.60
|
| Rate for Payer: Quartz Beloit One Network |
$3,162.95
|
| Rate for Payer: Quartz Commercial |
$3,873.00
|
| Rate for Payer: WEA Trust Commercial |
$3,550.25
|
| Rate for Payer: WPS Commercial |
$4,781.22
|
|
|
LASER FIBER HOLMIUM 200 FORTEC 10493
|
Facility
|
OP
|
$1,846.00
|
|
| Hospital Charge Code |
5349479
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$516.88 |
| Max. Negotiated Rate |
$7,384.00 |
| Rate for Payer: Aetna Commercial |
$1,661.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,587.56
|
| Rate for Payer: Aetna Managed Medicare |
$516.88
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,199.90
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$923.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$886.08
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$978.38
|
| Rate for Payer: Cash Price |
$553.80
|
| Rate for Payer: Cigna Commercial |
$1,698.32
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,033.02
|
| Rate for Payer: Health EOS Commercial |
$1,642.94
|
| Rate for Payer: HFN Commercial |
$1,698.32
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,384.50
|
| Rate for Payer: Multiplan Commercial |
$1,476.80
|
| Rate for Payer: NAPHCARE Commercial |
$1,107.60
|
| Rate for Payer: Preferred Network Access Commercial |
$1,698.32
|
| Rate for Payer: Quartz Beloit One Network |
$904.54
|
| Rate for Payer: Quartz Commercial |
$1,199.90
|
| Rate for Payer: Quartz Medicare Advantage |
$1,107.60
|
| Rate for Payer: The Alliance Commercial |
$7,384.00
|
| Rate for Payer: WEA Trust Commercial |
$1,015.30
|
| Rate for Payer: WPS Commercial |
$1,367.33
|
|
|
LASER FIBER HOLMIUM 200 FORTEC 10493
|
Facility
|
IP
|
$1,846.00
|
|
| Hospital Charge Code |
5349479
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$904.54 |
| Max. Negotiated Rate |
$1,698.32 |
| Rate for Payer: Aetna Commercial |
$1,661.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,587.56
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$978.38
|
| Rate for Payer: Cash Price |
$553.80
|
| Rate for Payer: Cigna Commercial |
$1,698.32
|
| Rate for Payer: Health EOS Commercial |
$1,642.94
|
| Rate for Payer: HFN Commercial |
$1,698.32
|
| Rate for Payer: Multiplan Commercial |
$1,476.80
|
| Rate for Payer: NAPHCARE Commercial |
$1,107.60
|
| Rate for Payer: Preferred Network Access Commercial |
$1,698.32
|
| Rate for Payer: Quartz Beloit One Network |
$904.54
|
| Rate for Payer: Quartz Commercial |
$1,107.60
|
| Rate for Payer: WEA Trust Commercial |
$1,015.30
|
| Rate for Payer: WPS Commercial |
$1,367.33
|
|
|
LASER FIBER HOLMIUM 273 SINGLE USE HLF-S273-SMA
|
Facility
|
OP
|
$4,351.00
|
|
| Hospital Charge Code |
3211469
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,218.28 |
| Max. Negotiated Rate |
$17,404.00 |
| Rate for Payer: Aetna Commercial |
$3,915.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,741.86
|
| Rate for Payer: Aetna Managed Medicare |
$1,218.28
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,828.15
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,175.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,088.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,306.03
|
| Rate for Payer: Cash Price |
$1,305.30
|
| Rate for Payer: Cigna Commercial |
$4,002.92
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,434.82
|
| Rate for Payer: Health EOS Commercial |
$3,872.39
|
| Rate for Payer: HFN Commercial |
$4,002.92
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,263.25
|
| Rate for Payer: Multiplan Commercial |
$3,480.80
|
| Rate for Payer: NAPHCARE Commercial |
$2,610.60
|
| Rate for Payer: Preferred Network Access Commercial |
$4,002.92
|
| Rate for Payer: Quartz Beloit One Network |
$2,131.99
|
| Rate for Payer: Quartz Commercial |
$2,828.15
|
| Rate for Payer: Quartz Medicare Advantage |
$2,610.60
|
| Rate for Payer: The Alliance Commercial |
$17,404.00
|
| Rate for Payer: WEA Trust Commercial |
$2,393.05
|
| Rate for Payer: WPS Commercial |
$3,222.79
|
|
|
LASER FIBER HOLMIUM 273 SINGLE USE HLF-S273-SMA
|
Facility
|
IP
|
$4,351.00
|
|
| Hospital Charge Code |
3211469
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$2,131.99 |
| Max. Negotiated Rate |
$4,002.92 |
| Rate for Payer: Aetna Commercial |
$3,915.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,741.86
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,306.03
|
| Rate for Payer: Cash Price |
$1,305.30
|
| Rate for Payer: Cigna Commercial |
$4,002.92
|
| Rate for Payer: Health EOS Commercial |
$3,872.39
|
| Rate for Payer: HFN Commercial |
$4,002.92
|
| Rate for Payer: Multiplan Commercial |
$3,480.80
|
| Rate for Payer: NAPHCARE Commercial |
$2,610.60
|
| Rate for Payer: Preferred Network Access Commercial |
$4,002.92
|
| Rate for Payer: Quartz Beloit One Network |
$2,131.99
|
| Rate for Payer: Quartz Commercial |
$2,610.60
|
| Rate for Payer: WEA Trust Commercial |
$2,393.05
|
| Rate for Payer: WPS Commercial |
$3,222.79
|
|
|
LASER FIBER HOLMIUM365 FORTEC SU-200-RT 11553
|
Facility
|
OP
|
$1,846.00
|
|
| Hospital Charge Code |
6184991
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$516.88 |
| Max. Negotiated Rate |
$7,384.00 |
| Rate for Payer: Aetna Commercial |
$1,661.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,587.56
|
| Rate for Payer: Aetna Managed Medicare |
$516.88
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,199.90
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$923.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$886.08
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$978.38
|
| Rate for Payer: Cash Price |
$553.80
|
| Rate for Payer: Cigna Commercial |
$1,698.32
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,033.02
|
| Rate for Payer: Health EOS Commercial |
$1,642.94
|
| Rate for Payer: HFN Commercial |
$1,698.32
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,384.50
|
| Rate for Payer: Multiplan Commercial |
$1,476.80
|
| Rate for Payer: NAPHCARE Commercial |
$1,107.60
|
| Rate for Payer: Preferred Network Access Commercial |
$1,698.32
|
| Rate for Payer: Quartz Beloit One Network |
$904.54
|
| Rate for Payer: Quartz Commercial |
$1,199.90
|
| Rate for Payer: Quartz Medicare Advantage |
$1,107.60
|
| Rate for Payer: The Alliance Commercial |
$7,384.00
|
| Rate for Payer: WEA Trust Commercial |
$1,015.30
|
| Rate for Payer: WPS Commercial |
$1,367.33
|
|
|
LASER FIBER HOLMIUM365 FORTEC SU-200-RT 11553
|
Facility
|
IP
|
$1,846.00
|
|
| Hospital Charge Code |
6184991
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$904.54 |
| Max. Negotiated Rate |
$1,698.32 |
| Rate for Payer: Aetna Commercial |
$1,661.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,587.56
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$978.38
|
| Rate for Payer: Cash Price |
$553.80
|
| Rate for Payer: Cigna Commercial |
$1,698.32
|
| Rate for Payer: Health EOS Commercial |
$1,642.94
|
| Rate for Payer: HFN Commercial |
$1,698.32
|
| Rate for Payer: Multiplan Commercial |
$1,476.80
|
| Rate for Payer: NAPHCARE Commercial |
$1,107.60
|
| Rate for Payer: Preferred Network Access Commercial |
$1,698.32
|
| Rate for Payer: Quartz Beloit One Network |
$904.54
|
| Rate for Payer: Quartz Commercial |
$1,107.60
|
| Rate for Payer: WEA Trust Commercial |
$1,015.30
|
| Rate for Payer: WPS Commercial |
$1,367.33
|
|
|
LASER FIBER HOLMIUM365 FORTEC SU-365-RT 11559
|
Facility
|
IP
|
$1,901.00
|
|
| Hospital Charge Code |
6184990
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$931.49 |
| Max. Negotiated Rate |
$1,748.92 |
| Rate for Payer: Aetna Commercial |
$1,710.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,634.86
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,007.53
|
| Rate for Payer: Cash Price |
$570.30
|
| Rate for Payer: Cigna Commercial |
$1,748.92
|
| Rate for Payer: Health EOS Commercial |
$1,691.89
|
| Rate for Payer: HFN Commercial |
$1,748.92
|
| Rate for Payer: Multiplan Commercial |
$1,520.80
|
| Rate for Payer: NAPHCARE Commercial |
$1,140.60
|
| Rate for Payer: Preferred Network Access Commercial |
$1,748.92
|
| Rate for Payer: Quartz Beloit One Network |
$931.49
|
| Rate for Payer: Quartz Commercial |
$1,140.60
|
| Rate for Payer: WEA Trust Commercial |
$1,045.55
|
| Rate for Payer: WPS Commercial |
$1,408.07
|
|
|
LASER FIBER HOLMIUM365 FORTEC SU-365-RT 11559
|
Facility
|
OP
|
$1,901.00
|
|
| Hospital Charge Code |
6184990
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$532.28 |
| Max. Negotiated Rate |
$7,604.00 |
| Rate for Payer: Aetna Commercial |
$1,710.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,634.86
|
| Rate for Payer: Aetna Managed Medicare |
$532.28
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,235.65
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$950.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$912.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,007.53
|
| Rate for Payer: Cash Price |
$570.30
|
| Rate for Payer: Cigna Commercial |
$1,748.92
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,063.80
|
| Rate for Payer: Health EOS Commercial |
$1,691.89
|
| Rate for Payer: HFN Commercial |
$1,748.92
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,425.75
|
| Rate for Payer: Multiplan Commercial |
$1,520.80
|
| Rate for Payer: NAPHCARE Commercial |
$1,140.60
|
| Rate for Payer: Preferred Network Access Commercial |
$1,748.92
|
| Rate for Payer: Quartz Beloit One Network |
$931.49
|
| Rate for Payer: Quartz Commercial |
$1,235.65
|
| Rate for Payer: Quartz Medicare Advantage |
$1,140.60
|
| Rate for Payer: The Alliance Commercial |
$7,604.00
|
| Rate for Payer: WEA Trust Commercial |
$1,045.55
|
| Rate for Payer: WPS Commercial |
$1,408.07
|
|
