|
BAG URINE NEWBORN STERILE
|
Facility
IP
|
$52.00
|
|
| Hospital Charge Code |
2963744
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$25.48 |
| Max. Negotiated Rate |
$47.84 |
| Rate for Payer: Aetna Commercial |
$46.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$27.56
|
| Rate for Payer: Cash Price |
$15.60
|
| Rate for Payer: Cigna Commercial |
$47.84
|
| Rate for Payer: Health EOS Commercial |
$46.28
|
| Rate for Payer: HFN Commercial |
$47.84
|
| Rate for Payer: Multiplan Commercial |
$41.60
|
| Rate for Payer: NAPHCARE Commercial |
$31.20
|
| Rate for Payer: Preferred Network Access Commercial |
$47.84
|
| Rate for Payer: Quartz Beloit One Network |
$25.48
|
| Rate for Payer: Quartz Commercial |
$31.20
|
| Rate for Payer: WEA Trust Commercial |
$28.60
|
| Rate for Payer: WPS Commercial |
$38.52
|
|
|
BAG URINE NEWBORN STERILE
|
Facility
OP
|
$52.00
|
|
| Hospital Charge Code |
2963744
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$14.56 |
| Max. Negotiated Rate |
$208.00 |
| Rate for Payer: Aetna Commercial |
$46.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$44.72
|
| Rate for Payer: Aetna Managed Medicare |
$14.56
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$33.80
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$26.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$24.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$27.56
|
| Rate for Payer: Cash Price |
$15.60
|
| Rate for Payer: Cigna Commercial |
$47.84
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$29.10
|
| Rate for Payer: Health EOS Commercial |
$46.28
|
| Rate for Payer: HFN Commercial |
$47.84
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$39.00
|
| Rate for Payer: Multiplan Commercial |
$41.60
|
| Rate for Payer: NAPHCARE Commercial |
$31.20
|
| Rate for Payer: Preferred Network Access Commercial |
$47.84
|
| Rate for Payer: Quartz Beloit One Network |
$25.48
|
| Rate for Payer: Quartz Commercial |
$33.80
|
| Rate for Payer: Quartz Medicare Advantage |
$31.20
|
| Rate for Payer: The Alliance Commercial |
$208.00
|
| Rate for Payer: WEA Trust Commercial |
$28.60
|
| Rate for Payer: WPS Commercial |
$38.52
|
|
|
BAG U STERILE PEDIATRIC SIZE
|
Facility
OP
|
$56.00
|
|
| Hospital Charge Code |
2964061
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$15.68 |
| Max. Negotiated Rate |
$224.00 |
| Rate for Payer: Quartz Commercial |
$36.40
|
| Rate for Payer: Aetna Commercial |
$50.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$48.16
|
| Rate for Payer: Aetna Managed Medicare |
$15.68
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$36.40
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$28.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$26.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$29.68
|
| Rate for Payer: Cash Price |
$16.80
|
| Rate for Payer: Cigna Commercial |
$51.52
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$31.34
|
| Rate for Payer: Health EOS Commercial |
$49.84
|
| Rate for Payer: HFN Commercial |
$51.52
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$42.00
|
| Rate for Payer: Multiplan Commercial |
$44.80
|
| Rate for Payer: NAPHCARE Commercial |
$33.60
|
| Rate for Payer: Preferred Network Access Commercial |
$51.52
|
| Rate for Payer: Quartz Beloit One Network |
$27.44
|
| Rate for Payer: Quartz Medicare Advantage |
$33.60
|
| Rate for Payer: The Alliance Commercial |
$224.00
|
| Rate for Payer: WEA Trust Commercial |
$30.80
|
| Rate for Payer: WPS Commercial |
$41.48
|
|
|
BAG U STERILE PEDIATRIC SIZE
|
Facility
IP
|
$56.00
|
|
| Hospital Charge Code |
2964061
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$27.44 |
| Max. Negotiated Rate |
$51.52 |
| Rate for Payer: Aetna Commercial |
$50.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$29.68
|
| Rate for Payer: Cash Price |
$16.80
|
| Rate for Payer: Cigna Commercial |
$51.52
|
| Rate for Payer: Health EOS Commercial |
$49.84
|
| Rate for Payer: HFN Commercial |
$51.52
|
| Rate for Payer: Multiplan Commercial |
$44.80
|
| Rate for Payer: NAPHCARE Commercial |
$33.60
|
| Rate for Payer: Preferred Network Access Commercial |
$51.52
|
| Rate for Payer: Quartz Beloit One Network |
$27.44
|
| Rate for Payer: Quartz Commercial |
$33.60
|
| Rate for Payer: WEA Trust Commercial |
$30.80
|
| Rate for Payer: WPS Commercial |
$41.48
|
|
|
Bakri Postpartum Balloon - Individual Charges
|
Facility
OP
|
$1,809.00
|
|
| Hospital Charge Code |
5082615
|
|
Hospital Revenue Code
|
720
|
| Min. Negotiated Rate |
$506.52 |
| Max. Negotiated Rate |
$7,236.00 |
| Rate for Payer: Aetna Commercial |
$1,628.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,555.74
|
| Rate for Payer: Aetna Managed Medicare |
$506.52
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,175.85
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$904.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$868.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$958.77
|
| Rate for Payer: Cash Price |
$542.70
|
| Rate for Payer: Cigna Commercial |
$1,664.28
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,012.32
|
| Rate for Payer: Health EOS Commercial |
$1,610.01
|
| Rate for Payer: HFN Commercial |
$1,664.28
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,356.75
|
| Rate for Payer: Multiplan Commercial |
$1,447.20
|
| Rate for Payer: NAPHCARE Commercial |
$1,085.40
|
| Rate for Payer: Preferred Network Access Commercial |
$1,664.28
|
| Rate for Payer: Quartz Beloit One Network |
$886.41
|
| Rate for Payer: Quartz Commercial |
$1,175.85
|
| Rate for Payer: Quartz Medicare Advantage |
$1,085.40
|
| Rate for Payer: The Alliance Commercial |
$7,236.00
|
| Rate for Payer: United Healthcare PPO |
$1,356.75
|
| Rate for Payer: WEA Trust Commercial |
$994.95
|
| Rate for Payer: WPS Commercial |
$1,339.93
|
|
|
Bakri Postpartum Balloon - Individual Charges
|
Facility
IP
|
$1,809.00
|
|
| Hospital Charge Code |
5082615
|
|
Hospital Revenue Code
|
720
|
| Min. Negotiated Rate |
$886.41 |
| Max. Negotiated Rate |
$1,664.28 |
| Rate for Payer: Aetna Commercial |
$1,628.10
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$958.77
|
| Rate for Payer: Cash Price |
$542.70
|
| Rate for Payer: Cigna Commercial |
$1,664.28
|
| Rate for Payer: Health EOS Commercial |
$1,610.01
|
| Rate for Payer: HFN Commercial |
$1,664.28
|
| Rate for Payer: Multiplan Commercial |
$1,447.20
|
| Rate for Payer: NAPHCARE Commercial |
$1,085.40
|
| Rate for Payer: Preferred Network Access Commercial |
$1,664.28
|
| Rate for Payer: Quartz Beloit One Network |
$886.41
|
| Rate for Payer: Quartz Commercial |
$1,085.40
|
| Rate for Payer: WEA Trust Commercial |
$994.95
|
| Rate for Payer: WPS Commercial |
$1,339.93
|
|
|
Balanced Salt Solution 15ml [Med]
|
Facility
IP
|
$21.00
|
|
| Hospital Charge Code |
2974916
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$10.29 |
| Max. Negotiated Rate |
$19.32 |
| Rate for Payer: Aetna Commercial |
$18.90
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$11.13
|
| Rate for Payer: Cash Price |
$6.30
|
| Rate for Payer: Cigna Commercial |
$19.32
|
| Rate for Payer: Health EOS Commercial |
$18.69
|
| Rate for Payer: HFN Commercial |
$19.32
|
| Rate for Payer: Multiplan Commercial |
$16.80
|
| Rate for Payer: NAPHCARE Commercial |
$12.60
|
| Rate for Payer: Preferred Network Access Commercial |
$19.32
|
| Rate for Payer: Quartz Beloit One Network |
$10.29
|
| Rate for Payer: Quartz Commercial |
$12.60
|
| Rate for Payer: WEA Trust Commercial |
$11.55
|
| Rate for Payer: WPS Commercial |
$15.55
|
|
|
Balanced Salt Solution 15ml [Med]
|
Facility
OP
|
$21.00
|
|
| Hospital Charge Code |
2974916
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5.88 |
| Max. Negotiated Rate |
$84.00 |
| Rate for Payer: Aetna Commercial |
$18.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$18.06
|
| Rate for Payer: Aetna Managed Medicare |
$5.88
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$13.65
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$10.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$10.08
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$11.13
|
| Rate for Payer: Cash Price |
$6.30
|
| Rate for Payer: Cigna Commercial |
$19.32
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$11.75
|
| Rate for Payer: Health EOS Commercial |
$18.69
|
| Rate for Payer: HFN Commercial |
$19.32
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$15.75
|
| Rate for Payer: Multiplan Commercial |
$16.80
|
| Rate for Payer: NAPHCARE Commercial |
$12.60
|
| Rate for Payer: Preferred Network Access Commercial |
$19.32
|
| Rate for Payer: Quartz Beloit One Network |
$10.29
|
| Rate for Payer: Quartz Commercial |
$13.65
|
| Rate for Payer: Quartz Medicare Advantage |
$12.60
|
| Rate for Payer: The Alliance Commercial |
$84.00
|
| Rate for Payer: WEA Trust Commercial |
$11.55
|
| Rate for Payer: WPS Commercial |
$15.55
|
|
|
Balanced Salt Solution 30ml [Med]
|
Facility
OP
|
$31.00
|
|
| Hospital Charge Code |
2974917
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.68 |
| Max. Negotiated Rate |
$124.00 |
| Rate for Payer: Aetna Commercial |
$27.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$26.66
|
| Rate for Payer: Aetna Managed Medicare |
$8.68
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$20.15
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$15.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$14.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$16.43
|
| Rate for Payer: Cash Price |
$9.30
|
| Rate for Payer: Cigna Commercial |
$28.52
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$17.35
|
| Rate for Payer: Health EOS Commercial |
$27.59
|
| Rate for Payer: HFN Commercial |
$28.52
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$23.25
|
| Rate for Payer: Multiplan Commercial |
$24.80
|
| Rate for Payer: NAPHCARE Commercial |
$18.60
|
| Rate for Payer: Preferred Network Access Commercial |
$28.52
|
| Rate for Payer: Quartz Beloit One Network |
$15.19
|
| Rate for Payer: Quartz Commercial |
$20.15
|
| Rate for Payer: Quartz Medicare Advantage |
$18.60
|
| Rate for Payer: The Alliance Commercial |
$124.00
|
| Rate for Payer: WEA Trust Commercial |
$17.05
|
| Rate for Payer: WPS Commercial |
$22.96
|
|
|
Balanced Salt Solution 30ml [Med]
|
Facility
IP
|
$31.00
|
|
| Hospital Charge Code |
2974917
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$15.19 |
| Max. Negotiated Rate |
$28.52 |
| Rate for Payer: Aetna Commercial |
$27.90
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$16.43
|
| Rate for Payer: Cash Price |
$9.30
|
| Rate for Payer: Cigna Commercial |
$28.52
|
| Rate for Payer: Health EOS Commercial |
$27.59
|
| Rate for Payer: HFN Commercial |
$28.52
|
| Rate for Payer: Multiplan Commercial |
$24.80
|
| Rate for Payer: NAPHCARE Commercial |
$18.60
|
| Rate for Payer: Preferred Network Access Commercial |
$28.52
|
| Rate for Payer: Quartz Beloit One Network |
$15.19
|
| Rate for Payer: Quartz Commercial |
$18.60
|
| Rate for Payer: WEA Trust Commercial |
$17.05
|
| Rate for Payer: WPS Commercial |
$22.96
|
|
|
BALLON NC 3.5 x8mm #1011756-08***DISCONTINUED
|
Facility
IP
|
$2,683.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
2973242
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,314.67 |
| Max. Negotiated Rate |
$2,468.36 |
| Rate for Payer: Aetna Commercial |
$2,414.70
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,421.99
|
| Rate for Payer: Cash Price |
$804.90
|
| Rate for Payer: Cigna Commercial |
$2,468.36
|
| Rate for Payer: Health EOS Commercial |
$2,387.87
|
| Rate for Payer: HFN Commercial |
$2,468.36
|
| Rate for Payer: Multiplan Commercial |
$2,146.40
|
| Rate for Payer: NAPHCARE Commercial |
$1,609.80
|
| Rate for Payer: Preferred Network Access Commercial |
$2,468.36
|
| Rate for Payer: Quartz Beloit One Network |
$1,314.67
|
| Rate for Payer: Quartz Commercial |
$1,609.80
|
| Rate for Payer: WEA Trust Commercial |
$1,475.65
|
| Rate for Payer: WPS Commercial |
$1,987.30
|
|
|
BALLON NC 3.5 x8mm #1011756-08***DISCONTINUED
|
Facility
OP
|
$2,683.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
2973242
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$751.24 |
| Max. Negotiated Rate |
$2,468.36 |
| Rate for Payer: Aetna Commercial |
$2,414.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,307.38
|
| Rate for Payer: Aetna Managed Medicare |
$751.24
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,743.95
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,341.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,287.84
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,421.99
|
| Rate for Payer: Cash Price |
$804.90
|
| Rate for Payer: Cigna Commercial |
$2,468.36
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,501.41
|
| Rate for Payer: Health EOS Commercial |
$2,387.87
|
| Rate for Payer: HFN Commercial |
$2,468.36
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,012.25
|
| Rate for Payer: Multiplan Commercial |
$2,146.40
|
| Rate for Payer: NAPHCARE Commercial |
$1,609.80
|
| Rate for Payer: Preferred Network Access Commercial |
$2,468.36
|
| Rate for Payer: Quartz Beloit One Network |
$1,314.67
|
| Rate for Payer: Quartz Commercial |
$1,743.95
|
| Rate for Payer: Quartz Medicare Advantage |
$1,609.80
|
| Rate for Payer: WEA Trust Commercial |
$1,475.65
|
| Rate for Payer: WPS Commercial |
$1,987.30
|
|
|
BALLOON 10 X20mm AB35W10020080
|
Facility
OP
|
$1,708.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
2972508
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$478.24 |
| Max. Negotiated Rate |
$1,571.36 |
| Rate for Payer: Aetna Commercial |
$1,537.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,468.88
|
| Rate for Payer: Aetna Managed Medicare |
$478.24
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,110.20
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$854.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$819.84
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$905.24
|
| Rate for Payer: Cash Price |
$512.40
|
| Rate for Payer: Cigna Commercial |
$1,571.36
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$955.80
|
| Rate for Payer: Health EOS Commercial |
$1,520.12
|
| Rate for Payer: HFN Commercial |
$1,571.36
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,281.00
|
| Rate for Payer: Multiplan Commercial |
$1,366.40
|
| Rate for Payer: NAPHCARE Commercial |
$1,024.80
|
| Rate for Payer: Preferred Network Access Commercial |
$1,571.36
|
| Rate for Payer: Quartz Beloit One Network |
$836.92
|
| Rate for Payer: Quartz Commercial |
$1,110.20
|
| Rate for Payer: Quartz Medicare Advantage |
$1,024.80
|
| Rate for Payer: WEA Trust Commercial |
$939.40
|
| Rate for Payer: WPS Commercial |
$1,265.12
|
|
|
BALLOON 10 X20mm AB35W10020080
|
Facility
IP
|
$1,708.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
2972508
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$836.92 |
| Max. Negotiated Rate |
$1,571.36 |
| Rate for Payer: Aetna Commercial |
$1,537.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$905.24
|
| Rate for Payer: Cash Price |
$512.40
|
| Rate for Payer: Cigna Commercial |
$1,571.36
|
| Rate for Payer: Health EOS Commercial |
$1,520.12
|
| Rate for Payer: HFN Commercial |
$1,571.36
|
| Rate for Payer: Multiplan Commercial |
$1,366.40
|
| Rate for Payer: NAPHCARE Commercial |
$1,024.80
|
| Rate for Payer: Preferred Network Access Commercial |
$1,571.36
|
| Rate for Payer: Quartz Beloit One Network |
$836.92
|
| Rate for Payer: Quartz Commercial |
$1,024.80
|
| Rate for Payer: WEA Trust Commercial |
$939.40
|
| Rate for Payer: WPS Commercial |
$1,265.12
|
|
|
BALLOON 10.X40mm AB35W10040080
|
Facility
OP
|
$1,708.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
2972514
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$478.24 |
| Max. Negotiated Rate |
$1,571.36 |
| Rate for Payer: Aetna Commercial |
$1,537.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,468.88
|
| Rate for Payer: Aetna Managed Medicare |
$478.24
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,110.20
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$854.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$819.84
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$905.24
|
| Rate for Payer: Cash Price |
$512.40
|
| Rate for Payer: Cigna Commercial |
$1,571.36
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$955.80
|
| Rate for Payer: Health EOS Commercial |
$1,520.12
|
| Rate for Payer: HFN Commercial |
$1,571.36
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,281.00
|
| Rate for Payer: Multiplan Commercial |
$1,366.40
|
| Rate for Payer: NAPHCARE Commercial |
$1,024.80
|
| Rate for Payer: Preferred Network Access Commercial |
$1,571.36
|
| Rate for Payer: Quartz Beloit One Network |
$836.92
|
| Rate for Payer: Quartz Commercial |
$1,110.20
|
| Rate for Payer: Quartz Medicare Advantage |
$1,024.80
|
| Rate for Payer: WEA Trust Commercial |
$939.40
|
| Rate for Payer: WPS Commercial |
$1,265.12
|
|
|
BALLOON 10.X40mm AB35W10040080
|
Facility
IP
|
$1,708.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
2972514
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$836.92 |
| Max. Negotiated Rate |
$1,571.36 |
| Rate for Payer: Aetna Commercial |
$1,537.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$905.24
|
| Rate for Payer: Cash Price |
$512.40
|
| Rate for Payer: Cigna Commercial |
$1,571.36
|
| Rate for Payer: Health EOS Commercial |
$1,520.12
|
| Rate for Payer: HFN Commercial |
$1,571.36
|
| Rate for Payer: Multiplan Commercial |
$1,366.40
|
| Rate for Payer: NAPHCARE Commercial |
$1,024.80
|
| Rate for Payer: Preferred Network Access Commercial |
$1,571.36
|
| Rate for Payer: Quartz Beloit One Network |
$836.92
|
| Rate for Payer: Quartz Commercial |
$1,024.80
|
| Rate for Payer: WEA Trust Commercial |
$939.40
|
| Rate for Payer: WPS Commercial |
$1,265.12
|
|
|
BALLOON 2.0 X 120 PTA
|
Facility
IP
|
$3,415.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
2973376
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,673.35 |
| Max. Negotiated Rate |
$3,141.80 |
| Rate for Payer: Aetna Commercial |
$3,073.50
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,809.95
|
| Rate for Payer: Cash Price |
$1,024.50
|
| Rate for Payer: Cigna Commercial |
$3,141.80
|
| Rate for Payer: Health EOS Commercial |
$3,039.35
|
| Rate for Payer: HFN Commercial |
$3,141.80
|
| Rate for Payer: Multiplan Commercial |
$2,732.00
|
| Rate for Payer: NAPHCARE Commercial |
$2,049.00
|
| Rate for Payer: Preferred Network Access Commercial |
$3,141.80
|
| Rate for Payer: Quartz Beloit One Network |
$1,673.35
|
| Rate for Payer: Quartz Commercial |
$2,049.00
|
| Rate for Payer: WEA Trust Commercial |
$1,878.25
|
| Rate for Payer: WPS Commercial |
$2,529.49
|
|
|
BALLOON 2.0 X 120 PTA
|
Facility
OP
|
$3,415.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
2973376
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$956.20 |
| Max. Negotiated Rate |
$3,141.80 |
| Rate for Payer: Aetna Commercial |
$3,073.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,936.90
|
| Rate for Payer: Aetna Managed Medicare |
$956.20
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,219.75
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,707.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,639.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,809.95
|
| Rate for Payer: Cash Price |
$1,024.50
|
| Rate for Payer: Cigna Commercial |
$3,141.80
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,911.03
|
| Rate for Payer: Health EOS Commercial |
$3,039.35
|
| Rate for Payer: HFN Commercial |
$3,141.80
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,561.25
|
| Rate for Payer: Multiplan Commercial |
$2,732.00
|
| Rate for Payer: NAPHCARE Commercial |
$2,049.00
|
| Rate for Payer: Preferred Network Access Commercial |
$3,141.80
|
| Rate for Payer: Quartz Beloit One Network |
$1,673.35
|
| Rate for Payer: Quartz Commercial |
$2,219.75
|
| Rate for Payer: Quartz Medicare Advantage |
$2,049.00
|
| Rate for Payer: WEA Trust Commercial |
$1,878.25
|
| Rate for Payer: WPS Commercial |
$2,529.49
|
|
|
BALLOON 2.0x15mm MAVERICK OTW
|
Facility
OP
|
$6,401.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
2972877
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,792.28 |
| Max. Negotiated Rate |
$5,888.92 |
| Rate for Payer: Aetna Commercial |
$5,760.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,504.86
|
| Rate for Payer: Aetna Managed Medicare |
$1,792.28
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,160.65
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,200.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,072.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,392.53
|
| Rate for Payer: Cash Price |
$1,920.30
|
| Rate for Payer: Cigna Commercial |
$5,888.92
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,582.00
|
| Rate for Payer: Health EOS Commercial |
$5,696.89
|
| Rate for Payer: HFN Commercial |
$5,888.92
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,800.75
|
| Rate for Payer: Multiplan Commercial |
$5,120.80
|
| Rate for Payer: NAPHCARE Commercial |
$3,840.60
|
| Rate for Payer: Preferred Network Access Commercial |
$5,888.92
|
| Rate for Payer: Quartz Beloit One Network |
$3,136.49
|
| Rate for Payer: Quartz Commercial |
$4,160.65
|
| Rate for Payer: Quartz Medicare Advantage |
$3,840.60
|
| Rate for Payer: WEA Trust Commercial |
$3,520.55
|
| Rate for Payer: WPS Commercial |
$4,741.22
|
|
|
BALLOON 2.0x15mm MAVERICK OTW
|
Facility
IP
|
$6,401.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
2972877
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$3,136.49 |
| Max. Negotiated Rate |
$5,888.92 |
| Rate for Payer: Aetna Commercial |
$5,760.90
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,392.53
|
| Rate for Payer: Cash Price |
$1,920.30
|
| Rate for Payer: Cigna Commercial |
$5,888.92
|
| Rate for Payer: Health EOS Commercial |
$5,696.89
|
| Rate for Payer: HFN Commercial |
$5,888.92
|
| Rate for Payer: Multiplan Commercial |
$5,120.80
|
| Rate for Payer: NAPHCARE Commercial |
$3,840.60
|
| Rate for Payer: Preferred Network Access Commercial |
$5,888.92
|
| Rate for Payer: Quartz Beloit One Network |
$3,136.49
|
| Rate for Payer: Quartz Commercial |
$3,840.60
|
| Rate for Payer: WEA Trust Commercial |
$3,520.55
|
| Rate for Payer: WPS Commercial |
$4,741.22
|
|
|
BALLOON 2.0x20mm MAVERICK OTW
|
Facility
IP
|
$3,660.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
2973424
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,793.40 |
| Max. Negotiated Rate |
$3,367.20 |
| Rate for Payer: Aetna Commercial |
$3,294.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,939.80
|
| Rate for Payer: Cash Price |
$1,098.00
|
| Rate for Payer: Cigna Commercial |
$3,367.20
|
| Rate for Payer: Health EOS Commercial |
$3,257.40
|
| Rate for Payer: HFN Commercial |
$3,367.20
|
| Rate for Payer: Multiplan Commercial |
$2,928.00
|
| Rate for Payer: NAPHCARE Commercial |
$2,196.00
|
| Rate for Payer: Preferred Network Access Commercial |
$3,367.20
|
| Rate for Payer: Quartz Beloit One Network |
$1,793.40
|
| Rate for Payer: Quartz Commercial |
$2,196.00
|
| Rate for Payer: WEA Trust Commercial |
$2,013.00
|
| Rate for Payer: WPS Commercial |
$2,710.96
|
|
|
BALLOON 2.0x20mm MAVERICK OTW
|
Facility
OP
|
$3,660.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
2973424
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,024.80 |
| Max. Negotiated Rate |
$3,367.20 |
| Rate for Payer: Aetna Commercial |
$3,294.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,147.60
|
| Rate for Payer: Aetna Managed Medicare |
$1,024.80
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,379.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,830.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,756.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,939.80
|
| Rate for Payer: Cash Price |
$1,098.00
|
| Rate for Payer: Cigna Commercial |
$3,367.20
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,048.14
|
| Rate for Payer: Health EOS Commercial |
$3,257.40
|
| Rate for Payer: HFN Commercial |
$3,367.20
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,745.00
|
| Rate for Payer: Multiplan Commercial |
$2,928.00
|
| Rate for Payer: NAPHCARE Commercial |
$2,196.00
|
| Rate for Payer: Preferred Network Access Commercial |
$3,367.20
|
| Rate for Payer: Quartz Beloit One Network |
$1,793.40
|
| Rate for Payer: Quartz Commercial |
$2,379.00
|
| Rate for Payer: Quartz Medicare Advantage |
$2,196.00
|
| Rate for Payer: WEA Trust Commercial |
$2,013.00
|
| Rate for Payer: WPS Commercial |
$2,710.96
|
|
|
BALLOON 2.5x15mm MAVERICK OTW
|
Facility
IP
|
$2,135.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
2972878
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,046.15 |
| Max. Negotiated Rate |
$1,964.20 |
| Rate for Payer: Aetna Commercial |
$1,921.50
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,131.55
|
| Rate for Payer: Cash Price |
$640.50
|
| Rate for Payer: Cigna Commercial |
$1,964.20
|
| Rate for Payer: Health EOS Commercial |
$1,900.15
|
| Rate for Payer: HFN Commercial |
$1,964.20
|
| Rate for Payer: Multiplan Commercial |
$1,708.00
|
| Rate for Payer: NAPHCARE Commercial |
$1,281.00
|
| Rate for Payer: Preferred Network Access Commercial |
$1,964.20
|
| Rate for Payer: Quartz Beloit One Network |
$1,046.15
|
| Rate for Payer: Quartz Commercial |
$1,281.00
|
| Rate for Payer: WEA Trust Commercial |
$1,174.25
|
| Rate for Payer: WPS Commercial |
$1,581.39
|
|
|
BALLOON 2.5x15mm MAVERICK OTW
|
Facility
OP
|
$2,135.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
2972878
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$597.80 |
| Max. Negotiated Rate |
$1,964.20 |
| Rate for Payer: Aetna Commercial |
$1,921.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,836.10
|
| Rate for Payer: Aetna Managed Medicare |
$597.80
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,387.75
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,067.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,024.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,131.55
|
| Rate for Payer: Cash Price |
$640.50
|
| Rate for Payer: Cigna Commercial |
$1,964.20
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,194.75
|
| Rate for Payer: Health EOS Commercial |
$1,900.15
|
| Rate for Payer: HFN Commercial |
$1,964.20
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,601.25
|
| Rate for Payer: Multiplan Commercial |
$1,708.00
|
| Rate for Payer: NAPHCARE Commercial |
$1,281.00
|
| Rate for Payer: Preferred Network Access Commercial |
$1,964.20
|
| Rate for Payer: Quartz Beloit One Network |
$1,046.15
|
| Rate for Payer: Quartz Commercial |
$1,387.75
|
| Rate for Payer: Quartz Medicare Advantage |
$1,281.00
|
| Rate for Payer: WEA Trust Commercial |
$1,174.25
|
| Rate for Payer: WPS Commercial |
$1,581.39
|
|
|
BALLOON 2.5 X 80mm
|
Facility
IP
|
$3,417.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
2973375
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,674.33 |
| Max. Negotiated Rate |
$3,143.64 |
| Rate for Payer: Aetna Commercial |
$3,075.30
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,811.01
|
| Rate for Payer: Cash Price |
$1,025.10
|
| Rate for Payer: Cigna Commercial |
$3,143.64
|
| Rate for Payer: Health EOS Commercial |
$3,041.13
|
| Rate for Payer: HFN Commercial |
$3,143.64
|
| Rate for Payer: Multiplan Commercial |
$2,733.60
|
| Rate for Payer: NAPHCARE Commercial |
$2,050.20
|
| Rate for Payer: Preferred Network Access Commercial |
$3,143.64
|
| Rate for Payer: Quartz Beloit One Network |
$1,674.33
|
| Rate for Payer: Quartz Commercial |
$2,050.20
|
| Rate for Payer: WEA Trust Commercial |
$1,879.35
|
| Rate for Payer: WPS Commercial |
$2,530.97
|
|
