|
BALLOON 4X 150mm AB35W04150135
|
Facility
OP
|
$1,753.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
2972687
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$490.84 |
| Max. Negotiated Rate |
$1,612.76 |
| Rate for Payer: Aetna Commercial |
$1,577.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,507.58
|
| Rate for Payer: Aetna Managed Medicare |
$490.84
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,139.45
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$876.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$841.44
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$929.09
|
| Rate for Payer: Cash Price |
$525.90
|
| Rate for Payer: Cigna Commercial |
$1,612.76
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$980.98
|
| Rate for Payer: Health EOS Commercial |
$1,560.17
|
| Rate for Payer: HFN Commercial |
$1,612.76
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,314.75
|
| Rate for Payer: Multiplan Commercial |
$1,402.40
|
| Rate for Payer: NAPHCARE Commercial |
$1,051.80
|
| Rate for Payer: Preferred Network Access Commercial |
$1,612.76
|
| Rate for Payer: Quartz Beloit One Network |
$858.97
|
| Rate for Payer: Quartz Commercial |
$1,139.45
|
| Rate for Payer: Quartz Medicare Advantage |
$1,051.80
|
| Rate for Payer: WEA Trust Commercial |
$964.15
|
| Rate for Payer: WPS Commercial |
$1,298.45
|
|
|
BALLOON 4X 150mm AB35W04150135
|
Facility
IP
|
$1,753.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
2972687
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$858.97 |
| Max. Negotiated Rate |
$1,612.76 |
| Rate for Payer: Aetna Commercial |
$1,577.70
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$929.09
|
| Rate for Payer: Cash Price |
$525.90
|
| Rate for Payer: Cigna Commercial |
$1,612.76
|
| Rate for Payer: Health EOS Commercial |
$1,560.17
|
| Rate for Payer: HFN Commercial |
$1,612.76
|
| Rate for Payer: Multiplan Commercial |
$1,402.40
|
| Rate for Payer: NAPHCARE Commercial |
$1,051.80
|
| Rate for Payer: Preferred Network Access Commercial |
$1,612.76
|
| Rate for Payer: Quartz Beloit One Network |
$858.97
|
| Rate for Payer: Quartz Commercial |
$1,051.80
|
| Rate for Payer: WEA Trust Commercial |
$964.15
|
| Rate for Payer: WPS Commercial |
$1,298.45
|
|
|
BALLOON 4.X 40mm AB35W04040135
|
Facility
IP
|
$2,288.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
2972939
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,121.12 |
| Max. Negotiated Rate |
$2,104.96 |
| Rate for Payer: Aetna Commercial |
$2,059.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,212.64
|
| Rate for Payer: Cash Price |
$686.40
|
| Rate for Payer: Cigna Commercial |
$2,104.96
|
| Rate for Payer: Health EOS Commercial |
$2,036.32
|
| Rate for Payer: HFN Commercial |
$2,104.96
|
| Rate for Payer: Multiplan Commercial |
$1,830.40
|
| Rate for Payer: NAPHCARE Commercial |
$1,372.80
|
| Rate for Payer: Preferred Network Access Commercial |
$2,104.96
|
| Rate for Payer: Quartz Beloit One Network |
$1,121.12
|
| Rate for Payer: Quartz Commercial |
$1,372.80
|
| Rate for Payer: WEA Trust Commercial |
$1,258.40
|
| Rate for Payer: WPS Commercial |
$1,694.72
|
|
|
BALLOON 4.X 40mm AB35W04040135
|
Facility
OP
|
$2,288.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
2972939
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$640.64 |
| Max. Negotiated Rate |
$2,104.96 |
| Rate for Payer: Aetna Commercial |
$2,059.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,967.68
|
| Rate for Payer: Aetna Managed Medicare |
$640.64
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,487.20
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,144.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,098.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,212.64
|
| Rate for Payer: Cash Price |
$686.40
|
| Rate for Payer: Cigna Commercial |
$2,104.96
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,280.36
|
| Rate for Payer: Health EOS Commercial |
$2,036.32
|
| Rate for Payer: HFN Commercial |
$2,104.96
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,716.00
|
| Rate for Payer: Multiplan Commercial |
$1,830.40
|
| Rate for Payer: NAPHCARE Commercial |
$1,372.80
|
| Rate for Payer: Preferred Network Access Commercial |
$2,104.96
|
| Rate for Payer: Quartz Beloit One Network |
$1,121.12
|
| Rate for Payer: Quartz Commercial |
$1,487.20
|
| Rate for Payer: Quartz Medicare Advantage |
$1,372.80
|
| Rate for Payer: WEA Trust Commercial |
$1,258.40
|
| Rate for Payer: WPS Commercial |
$1,694.72
|
|
|
BALLOON 4x4 HURRICANE DILATOR 4590
|
Facility
OP
|
$2,794.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
2973260
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$782.32 |
| Max. Negotiated Rate |
$2,570.48 |
| Rate for Payer: Aetna Commercial |
$2,514.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,402.84
|
| Rate for Payer: Aetna Managed Medicare |
$782.32
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,816.10
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,397.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,341.12
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,480.82
|
| Rate for Payer: Cash Price |
$838.20
|
| Rate for Payer: Cigna Commercial |
$2,570.48
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,563.52
|
| Rate for Payer: Health EOS Commercial |
$2,486.66
|
| Rate for Payer: HFN Commercial |
$2,570.48
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,095.50
|
| Rate for Payer: Multiplan Commercial |
$2,235.20
|
| Rate for Payer: NAPHCARE Commercial |
$1,676.40
|
| Rate for Payer: Preferred Network Access Commercial |
$2,570.48
|
| Rate for Payer: Quartz Beloit One Network |
$1,369.06
|
| Rate for Payer: Quartz Commercial |
$1,816.10
|
| Rate for Payer: Quartz Medicare Advantage |
$1,676.40
|
| Rate for Payer: WEA Trust Commercial |
$1,536.70
|
| Rate for Payer: WPS Commercial |
$2,069.52
|
|
|
BALLOON 4x4 HURRICANE DILATOR 4590
|
Facility
IP
|
$2,794.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
2973260
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,369.06 |
| Max. Negotiated Rate |
$2,570.48 |
| Rate for Payer: Aetna Commercial |
$2,514.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,480.82
|
| Rate for Payer: Cash Price |
$838.20
|
| Rate for Payer: Cigna Commercial |
$2,570.48
|
| Rate for Payer: Health EOS Commercial |
$2,486.66
|
| Rate for Payer: HFN Commercial |
$2,570.48
|
| Rate for Payer: Multiplan Commercial |
$2,235.20
|
| Rate for Payer: NAPHCARE Commercial |
$1,676.40
|
| Rate for Payer: Preferred Network Access Commercial |
$2,570.48
|
| Rate for Payer: Quartz Beloit One Network |
$1,369.06
|
| Rate for Payer: Quartz Commercial |
$1,676.40
|
| Rate for Payer: WEA Trust Commercial |
$1,536.70
|
| Rate for Payer: WPS Commercial |
$2,069.52
|
|
|
BALLOON 4 x 60mm AB35W04060135
|
Facility
OP
|
$1,708.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
2972490
|
|
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 4 x 60mm AB35W04060135
|
Facility
IP
|
$1,708.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
2972490
|
|
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 4x6 HURRICANE DILATOR 4592
|
Facility
IP
|
$2,902.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
2973261
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,421.98 |
| Max. Negotiated Rate |
$2,669.84 |
| Rate for Payer: Aetna Commercial |
$2,611.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,538.06
|
| Rate for Payer: Cash Price |
$870.60
|
| Rate for Payer: Cigna Commercial |
$2,669.84
|
| Rate for Payer: Health EOS Commercial |
$2,582.78
|
| Rate for Payer: HFN Commercial |
$2,669.84
|
| Rate for Payer: Multiplan Commercial |
$2,321.60
|
| Rate for Payer: NAPHCARE Commercial |
$1,741.20
|
| Rate for Payer: Preferred Network Access Commercial |
$2,669.84
|
| Rate for Payer: Quartz Beloit One Network |
$1,421.98
|
| Rate for Payer: Quartz Commercial |
$1,741.20
|
| Rate for Payer: WEA Trust Commercial |
$1,596.10
|
| Rate for Payer: WPS Commercial |
$2,149.51
|
|
|
BALLOON 4x6 HURRICANE DILATOR 4592
|
Facility
OP
|
$2,902.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
2973261
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$812.56 |
| Max. Negotiated Rate |
$2,669.84 |
| Rate for Payer: Aetna Commercial |
$2,611.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,495.72
|
| Rate for Payer: Aetna Managed Medicare |
$812.56
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,886.30
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,451.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,392.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,538.06
|
| Rate for Payer: Cash Price |
$870.60
|
| Rate for Payer: Cigna Commercial |
$2,669.84
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,623.96
|
| Rate for Payer: Health EOS Commercial |
$2,582.78
|
| Rate for Payer: HFN Commercial |
$2,669.84
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,176.50
|
| Rate for Payer: Multiplan Commercial |
$2,321.60
|
| Rate for Payer: NAPHCARE Commercial |
$1,741.20
|
| Rate for Payer: Preferred Network Access Commercial |
$2,669.84
|
| Rate for Payer: Quartz Beloit One Network |
$1,421.98
|
| Rate for Payer: Quartz Commercial |
$1,886.30
|
| Rate for Payer: Quartz Medicare Advantage |
$1,741.20
|
| Rate for Payer: WEA Trust Commercial |
$1,596.10
|
| Rate for Payer: WPS Commercial |
$2,149.51
|
|
|
BALLOON 5.0 X 60 AB35W05060080
|
Facility
IP
|
$1,708.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
2972936
|
|
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 5.0 X 60 AB35W05060080
|
Facility
OP
|
$1,708.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
2972936
|
|
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 5X 100mm AB35W05100135
|
Facility
IP
|
$1,708.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
2972486
|
|
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 5X 100mm AB35W05100135
|
Facility
OP
|
$1,708.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
2972486
|
|
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 5X 120mm AB35W05120135
|
Facility
OP
|
$2,287.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
2972929
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$640.36 |
| Max. Negotiated Rate |
$2,104.04 |
| Rate for Payer: Aetna Commercial |
$2,058.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,966.82
|
| Rate for Payer: Aetna Managed Medicare |
$640.36
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,486.55
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,143.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,097.76
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,212.11
|
| Rate for Payer: Cash Price |
$686.10
|
| Rate for Payer: Cigna Commercial |
$2,104.04
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,279.81
|
| Rate for Payer: Health EOS Commercial |
$2,035.43
|
| Rate for Payer: HFN Commercial |
$2,104.04
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,715.25
|
| Rate for Payer: Multiplan Commercial |
$1,829.60
|
| Rate for Payer: NAPHCARE Commercial |
$1,372.20
|
| Rate for Payer: Preferred Network Access Commercial |
$2,104.04
|
| Rate for Payer: Quartz Beloit One Network |
$1,120.63
|
| Rate for Payer: Quartz Commercial |
$1,486.55
|
| Rate for Payer: Quartz Medicare Advantage |
$1,372.20
|
| Rate for Payer: WEA Trust Commercial |
$1,257.85
|
| Rate for Payer: WPS Commercial |
$1,693.98
|
|
|
BALLOON 5X 120mm AB35W05120135
|
Facility
IP
|
$2,287.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
2972929
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,120.63 |
| Max. Negotiated Rate |
$2,104.04 |
| Rate for Payer: Aetna Commercial |
$2,058.30
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,212.11
|
| Rate for Payer: Cash Price |
$686.10
|
| Rate for Payer: Cigna Commercial |
$2,104.04
|
| Rate for Payer: Health EOS Commercial |
$2,035.43
|
| Rate for Payer: HFN Commercial |
$2,104.04
|
| Rate for Payer: Multiplan Commercial |
$1,829.60
|
| Rate for Payer: NAPHCARE Commercial |
$1,372.20
|
| Rate for Payer: Preferred Network Access Commercial |
$2,104.04
|
| Rate for Payer: Quartz Beloit One Network |
$1,120.63
|
| Rate for Payer: Quartz Commercial |
$1,372.20
|
| Rate for Payer: WEA Trust Commercial |
$1,257.85
|
| Rate for Payer: WPS Commercial |
$1,693.98
|
|
|
BALLOON 5X 150mm AB35W05150135
|
Facility
IP
|
$1,753.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
2972686
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$858.97 |
| Max. Negotiated Rate |
$1,612.76 |
| Rate for Payer: Aetna Commercial |
$1,577.70
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$929.09
|
| Rate for Payer: Cash Price |
$525.90
|
| Rate for Payer: Cigna Commercial |
$1,612.76
|
| Rate for Payer: Health EOS Commercial |
$1,560.17
|
| Rate for Payer: HFN Commercial |
$1,612.76
|
| Rate for Payer: Multiplan Commercial |
$1,402.40
|
| Rate for Payer: NAPHCARE Commercial |
$1,051.80
|
| Rate for Payer: Preferred Network Access Commercial |
$1,612.76
|
| Rate for Payer: Quartz Beloit One Network |
$858.97
|
| Rate for Payer: Quartz Commercial |
$1,051.80
|
| Rate for Payer: WEA Trust Commercial |
$964.15
|
| Rate for Payer: WPS Commercial |
$1,298.45
|
|
|
BALLOON 5X 150mm AB35W05150135
|
Facility
OP
|
$1,753.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
2972686
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$490.84 |
| Max. Negotiated Rate |
$1,612.76 |
| Rate for Payer: Aetna Commercial |
$1,577.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,507.58
|
| Rate for Payer: Aetna Managed Medicare |
$490.84
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,139.45
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$876.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$841.44
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$929.09
|
| Rate for Payer: Cash Price |
$525.90
|
| Rate for Payer: Cigna Commercial |
$1,612.76
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$980.98
|
| Rate for Payer: Health EOS Commercial |
$1,560.17
|
| Rate for Payer: HFN Commercial |
$1,612.76
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,314.75
|
| Rate for Payer: Multiplan Commercial |
$1,402.40
|
| Rate for Payer: NAPHCARE Commercial |
$1,051.80
|
| Rate for Payer: Preferred Network Access Commercial |
$1,612.76
|
| Rate for Payer: Quartz Beloit One Network |
$858.97
|
| Rate for Payer: Quartz Commercial |
$1,139.45
|
| Rate for Payer: Quartz Medicare Advantage |
$1,051.80
|
| Rate for Payer: WEA Trust Commercial |
$964.15
|
| Rate for Payer: WPS Commercial |
$1,298.45
|
|
|
BALLOON 5 X 20mm AB35W05020135
|
Facility
IP
|
$1,708.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
2972503
|
|
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 5 X 20mm AB35W05020135
|
Facility
OP
|
$1,708.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
2972503
|
|
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 5 X 40mm AB35W05040080
|
Facility
OP
|
$1,525.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
2972495
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$427.00 |
| Max. Negotiated Rate |
$1,403.00 |
| Rate for Payer: Aetna Commercial |
$1,372.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,311.50
|
| Rate for Payer: Aetna Managed Medicare |
$427.00
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$991.25
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$762.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$732.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$808.25
|
| Rate for Payer: Cash Price |
$457.50
|
| Rate for Payer: Cigna Commercial |
$1,403.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$853.39
|
| Rate for Payer: Health EOS Commercial |
$1,357.25
|
| Rate for Payer: HFN Commercial |
$1,403.00
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,143.75
|
| Rate for Payer: Multiplan Commercial |
$1,220.00
|
| Rate for Payer: NAPHCARE Commercial |
$915.00
|
| Rate for Payer: Preferred Network Access Commercial |
$1,403.00
|
| Rate for Payer: Quartz Beloit One Network |
$747.25
|
| Rate for Payer: Quartz Commercial |
$991.25
|
| Rate for Payer: Quartz Medicare Advantage |
$915.00
|
| Rate for Payer: WEA Trust Commercial |
$838.75
|
| Rate for Payer: WPS Commercial |
$1,129.57
|
|
|
BALLOON 5 X 40mm AB35W05040080
|
Facility
IP
|
$1,525.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
2972495
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$747.25 |
| Max. Negotiated Rate |
$1,403.00 |
| Rate for Payer: Aetna Commercial |
$1,372.50
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$808.25
|
| Rate for Payer: Cash Price |
$457.50
|
| Rate for Payer: Cigna Commercial |
$1,403.00
|
| Rate for Payer: Health EOS Commercial |
$1,357.25
|
| Rate for Payer: HFN Commercial |
$1,403.00
|
| Rate for Payer: Multiplan Commercial |
$1,220.00
|
| Rate for Payer: NAPHCARE Commercial |
$915.00
|
| Rate for Payer: Preferred Network Access Commercial |
$1,403.00
|
| Rate for Payer: Quartz Beloit One Network |
$747.25
|
| Rate for Payer: Quartz Commercial |
$915.00
|
| Rate for Payer: WEA Trust Commercial |
$838.75
|
| Rate for Payer: WPS Commercial |
$1,129.57
|
|
|
BALLOON 5 X 60mm AB35W05060135
|
Facility
OP
|
$1,708.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
2972494
|
|
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 5 X 60mm AB35W05060135
|
Facility
IP
|
$1,708.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
2972494
|
|
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 6X 100mm AB35W06100135
|
Facility
OP
|
$1,708.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
2972487
|
|
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
|
|
