|
BALLOON CERVICAL RIPENING/STYLET G19891
|
Facility
OP
|
$849.00
|
|
| Hospital Charge Code |
5178771
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$237.72 |
| Max. Negotiated Rate |
$3,396.00 |
| Rate for Payer: Aetna Commercial |
$764.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$730.14
|
| Rate for Payer: Aetna Managed Medicare |
$237.72
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$551.85
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$424.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$407.52
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$449.97
|
| Rate for Payer: Cash Price |
$254.70
|
| Rate for Payer: Cigna Commercial |
$781.08
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$475.10
|
| Rate for Payer: Health EOS Commercial |
$755.61
|
| Rate for Payer: HFN Commercial |
$781.08
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$636.75
|
| Rate for Payer: Multiplan Commercial |
$679.20
|
| Rate for Payer: NAPHCARE Commercial |
$509.40
|
| Rate for Payer: Preferred Network Access Commercial |
$781.08
|
| Rate for Payer: Quartz Beloit One Network |
$416.01
|
| Rate for Payer: Quartz Commercial |
$551.85
|
| Rate for Payer: Quartz Medicare Advantage |
$509.40
|
| Rate for Payer: The Alliance Commercial |
$3,396.00
|
| Rate for Payer: WEA Trust Commercial |
$466.95
|
| Rate for Payer: WPS Commercial |
$628.85
|
|
|
BALLOON CERVICAL RIPENING/STYLET G19891
|
Facility
IP
|
$849.00
|
|
| Hospital Charge Code |
5178771
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$416.01 |
| Max. Negotiated Rate |
$781.08 |
| Rate for Payer: Aetna Commercial |
$764.10
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$449.97
|
| Rate for Payer: Cash Price |
$254.70
|
| Rate for Payer: Cigna Commercial |
$781.08
|
| Rate for Payer: Health EOS Commercial |
$755.61
|
| Rate for Payer: HFN Commercial |
$781.08
|
| Rate for Payer: Multiplan Commercial |
$679.20
|
| Rate for Payer: NAPHCARE Commercial |
$509.40
|
| Rate for Payer: Preferred Network Access Commercial |
$781.08
|
| Rate for Payer: Quartz Beloit One Network |
$416.01
|
| Rate for Payer: Quartz Commercial |
$509.40
|
| Rate for Payer: WEA Trust Commercial |
$466.95
|
| Rate for Payer: WPS Commercial |
$628.85
|
|
|
BALLOON CONQUEST 40 10MM X 2CM X 75CM X 5.8F X .035 CQF75102
|
Facility
OP
|
$2,005.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
6204999
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$561.40 |
| Max. Negotiated Rate |
$1,844.60 |
| Rate for Payer: Aetna Commercial |
$1,804.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,724.30
|
| Rate for Payer: Aetna Managed Medicare |
$561.40
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,303.25
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,002.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$962.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,062.65
|
| Rate for Payer: Cash Price |
$601.50
|
| Rate for Payer: Cigna Commercial |
$1,844.60
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,122.00
|
| Rate for Payer: Health EOS Commercial |
$1,784.45
|
| Rate for Payer: HFN Commercial |
$1,844.60
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,503.75
|
| Rate for Payer: Multiplan Commercial |
$1,604.00
|
| Rate for Payer: NAPHCARE Commercial |
$1,203.00
|
| Rate for Payer: Preferred Network Access Commercial |
$1,844.60
|
| Rate for Payer: Quartz Beloit One Network |
$982.45
|
| Rate for Payer: Quartz Commercial |
$1,303.25
|
| Rate for Payer: Quartz Medicare Advantage |
$1,203.00
|
| Rate for Payer: WEA Trust Commercial |
$1,102.75
|
| Rate for Payer: WPS Commercial |
$1,485.10
|
|
|
BALLOON CONQUEST 40 10MM X 2CM X 75CM X 5.8F X .035 CQF75102
|
Facility
IP
|
$2,005.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
6204999
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$982.45 |
| Max. Negotiated Rate |
$1,844.60 |
| Rate for Payer: Aetna Commercial |
$1,804.50
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,062.65
|
| Rate for Payer: Cash Price |
$601.50
|
| Rate for Payer: Cigna Commercial |
$1,844.60
|
| Rate for Payer: Health EOS Commercial |
$1,784.45
|
| Rate for Payer: HFN Commercial |
$1,844.60
|
| Rate for Payer: Multiplan Commercial |
$1,604.00
|
| Rate for Payer: NAPHCARE Commercial |
$1,203.00
|
| Rate for Payer: Preferred Network Access Commercial |
$1,844.60
|
| Rate for Payer: Quartz Beloit One Network |
$982.45
|
| Rate for Payer: Quartz Commercial |
$1,203.00
|
| Rate for Payer: WEA Trust Commercial |
$1,102.75
|
| Rate for Payer: WPS Commercial |
$1,485.10
|
|
|
BALLOON CONQUEST 40 10MM X 4CM X 75CM X 5.8F X .035 CQF75104
|
Facility
IP
|
$2,005.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
6205000
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$982.45 |
| Max. Negotiated Rate |
$1,844.60 |
| Rate for Payer: Aetna Commercial |
$1,804.50
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,062.65
|
| Rate for Payer: Cash Price |
$601.50
|
| Rate for Payer: Cigna Commercial |
$1,844.60
|
| Rate for Payer: Health EOS Commercial |
$1,784.45
|
| Rate for Payer: HFN Commercial |
$1,844.60
|
| Rate for Payer: Multiplan Commercial |
$1,604.00
|
| Rate for Payer: NAPHCARE Commercial |
$1,203.00
|
| Rate for Payer: Preferred Network Access Commercial |
$1,844.60
|
| Rate for Payer: Quartz Beloit One Network |
$982.45
|
| Rate for Payer: Quartz Commercial |
$1,203.00
|
| Rate for Payer: WEA Trust Commercial |
$1,102.75
|
| Rate for Payer: WPS Commercial |
$1,485.10
|
|
|
BALLOON CONQUEST 40 10MM X 4CM X 75CM X 5.8F X .035 CQF75104
|
Facility
OP
|
$2,005.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
6205000
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$561.40 |
| Max. Negotiated Rate |
$1,844.60 |
| Rate for Payer: Aetna Commercial |
$1,804.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,724.30
|
| Rate for Payer: Aetna Managed Medicare |
$561.40
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,303.25
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,002.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$962.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,062.65
|
| Rate for Payer: Cash Price |
$601.50
|
| Rate for Payer: Cigna Commercial |
$1,844.60
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,122.00
|
| Rate for Payer: Health EOS Commercial |
$1,784.45
|
| Rate for Payer: HFN Commercial |
$1,844.60
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,503.75
|
| Rate for Payer: Multiplan Commercial |
$1,604.00
|
| Rate for Payer: NAPHCARE Commercial |
$1,203.00
|
| Rate for Payer: Preferred Network Access Commercial |
$1,844.60
|
| Rate for Payer: Quartz Beloit One Network |
$982.45
|
| Rate for Payer: Quartz Commercial |
$1,303.25
|
| Rate for Payer: Quartz Medicare Advantage |
$1,203.00
|
| Rate for Payer: WEA Trust Commercial |
$1,102.75
|
| Rate for Payer: WPS Commercial |
$1,485.10
|
|
|
BALLOON CONQUEST 40 10MM X 8CM X 75CM X 5.8F X .035 CQF75108
|
Facility
OP
|
$2,005.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
6205001
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$561.40 |
| Max. Negotiated Rate |
$1,844.60 |
| Rate for Payer: Aetna Commercial |
$1,804.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,724.30
|
| Rate for Payer: Aetna Managed Medicare |
$561.40
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,303.25
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,002.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$962.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,062.65
|
| Rate for Payer: Cash Price |
$601.50
|
| Rate for Payer: Cigna Commercial |
$1,844.60
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,122.00
|
| Rate for Payer: Health EOS Commercial |
$1,784.45
|
| Rate for Payer: HFN Commercial |
$1,844.60
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,503.75
|
| Rate for Payer: Multiplan Commercial |
$1,604.00
|
| Rate for Payer: NAPHCARE Commercial |
$1,203.00
|
| Rate for Payer: Preferred Network Access Commercial |
$1,844.60
|
| Rate for Payer: Quartz Beloit One Network |
$982.45
|
| Rate for Payer: Quartz Commercial |
$1,303.25
|
| Rate for Payer: Quartz Medicare Advantage |
$1,203.00
|
| Rate for Payer: WEA Trust Commercial |
$1,102.75
|
| Rate for Payer: WPS Commercial |
$1,485.10
|
|
|
BALLOON CONQUEST 40 10MM X 8CM X 75CM X 5.8F X .035 CQF75108
|
Facility
IP
|
$2,005.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
6205001
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$982.45 |
| Max. Negotiated Rate |
$1,844.60 |
| Rate for Payer: Aetna Commercial |
$1,804.50
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,062.65
|
| Rate for Payer: Cash Price |
$601.50
|
| Rate for Payer: Cigna Commercial |
$1,844.60
|
| Rate for Payer: Health EOS Commercial |
$1,784.45
|
| Rate for Payer: HFN Commercial |
$1,844.60
|
| Rate for Payer: Multiplan Commercial |
$1,604.00
|
| Rate for Payer: NAPHCARE Commercial |
$1,203.00
|
| Rate for Payer: Preferred Network Access Commercial |
$1,844.60
|
| Rate for Payer: Quartz Beloit One Network |
$982.45
|
| Rate for Payer: Quartz Commercial |
$1,203.00
|
| Rate for Payer: WEA Trust Commercial |
$1,102.75
|
| Rate for Payer: WPS Commercial |
$1,485.10
|
|
|
BALLOON CONQUEST 40 12MM X 4CM X 75CM X 6.5F X .035 CQF75124
|
Facility
OP
|
$2,005.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
6205002
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$561.40 |
| Max. Negotiated Rate |
$1,844.60 |
| Rate for Payer: Aetna Commercial |
$1,804.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,724.30
|
| Rate for Payer: Aetna Managed Medicare |
$561.40
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,303.25
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,002.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$962.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,062.65
|
| Rate for Payer: Cash Price |
$601.50
|
| Rate for Payer: Cigna Commercial |
$1,844.60
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,122.00
|
| Rate for Payer: Health EOS Commercial |
$1,784.45
|
| Rate for Payer: HFN Commercial |
$1,844.60
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,503.75
|
| Rate for Payer: Multiplan Commercial |
$1,604.00
|
| Rate for Payer: NAPHCARE Commercial |
$1,203.00
|
| Rate for Payer: Preferred Network Access Commercial |
$1,844.60
|
| Rate for Payer: Quartz Beloit One Network |
$982.45
|
| Rate for Payer: Quartz Commercial |
$1,303.25
|
| Rate for Payer: Quartz Medicare Advantage |
$1,203.00
|
| Rate for Payer: WEA Trust Commercial |
$1,102.75
|
| Rate for Payer: WPS Commercial |
$1,485.10
|
|
|
BALLOON CONQUEST 40 12MM X 4CM X 75CM X 6.5F X .035 CQF75124
|
Facility
IP
|
$2,005.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
6205002
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$982.45 |
| Max. Negotiated Rate |
$1,844.60 |
| Rate for Payer: Aetna Commercial |
$1,804.50
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,062.65
|
| Rate for Payer: Cash Price |
$601.50
|
| Rate for Payer: Cigna Commercial |
$1,844.60
|
| Rate for Payer: Health EOS Commercial |
$1,784.45
|
| Rate for Payer: HFN Commercial |
$1,844.60
|
| Rate for Payer: Multiplan Commercial |
$1,604.00
|
| Rate for Payer: NAPHCARE Commercial |
$1,203.00
|
| Rate for Payer: Preferred Network Access Commercial |
$1,844.60
|
| Rate for Payer: Quartz Beloit One Network |
$982.45
|
| Rate for Payer: Quartz Commercial |
$1,203.00
|
| Rate for Payer: WEA Trust Commercial |
$1,102.75
|
| Rate for Payer: WPS Commercial |
$1,485.10
|
|
|
BALLOON CONQUEST 40 4MM X 2CM X 75CM X 5.8F X .035 CQF7542
|
Facility
IP
|
$2,005.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
6205003
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$982.45 |
| Max. Negotiated Rate |
$1,844.60 |
| Rate for Payer: Aetna Commercial |
$1,804.50
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,062.65
|
| Rate for Payer: Cash Price |
$601.50
|
| Rate for Payer: Cigna Commercial |
$1,844.60
|
| Rate for Payer: Health EOS Commercial |
$1,784.45
|
| Rate for Payer: HFN Commercial |
$1,844.60
|
| Rate for Payer: Multiplan Commercial |
$1,604.00
|
| Rate for Payer: NAPHCARE Commercial |
$1,203.00
|
| Rate for Payer: Preferred Network Access Commercial |
$1,844.60
|
| Rate for Payer: Quartz Beloit One Network |
$982.45
|
| Rate for Payer: Quartz Commercial |
$1,203.00
|
| Rate for Payer: WEA Trust Commercial |
$1,102.75
|
| Rate for Payer: WPS Commercial |
$1,485.10
|
|
|
BALLOON CONQUEST 40 4MM X 2CM X 75CM X 5.8F X .035 CQF7542
|
Facility
OP
|
$2,005.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
6205003
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$561.40 |
| Max. Negotiated Rate |
$1,844.60 |
| Rate for Payer: Aetna Commercial |
$1,804.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,724.30
|
| Rate for Payer: Aetna Managed Medicare |
$561.40
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,303.25
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,002.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$962.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,062.65
|
| Rate for Payer: Cash Price |
$601.50
|
| Rate for Payer: Cigna Commercial |
$1,844.60
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,122.00
|
| Rate for Payer: Health EOS Commercial |
$1,784.45
|
| Rate for Payer: HFN Commercial |
$1,844.60
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,503.75
|
| Rate for Payer: Multiplan Commercial |
$1,604.00
|
| Rate for Payer: NAPHCARE Commercial |
$1,203.00
|
| Rate for Payer: Preferred Network Access Commercial |
$1,844.60
|
| Rate for Payer: Quartz Beloit One Network |
$982.45
|
| Rate for Payer: Quartz Commercial |
$1,303.25
|
| Rate for Payer: Quartz Medicare Advantage |
$1,203.00
|
| Rate for Payer: WEA Trust Commercial |
$1,102.75
|
| Rate for Payer: WPS Commercial |
$1,485.10
|
|
|
BALLOON CONQUEST 40 4MM X 4CM X 75CM X 5.8F X .035 CQF7544
|
Facility
IP
|
$2,005.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
6205004
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$982.45 |
| Max. Negotiated Rate |
$1,844.60 |
| Rate for Payer: Aetna Commercial |
$1,804.50
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,062.65
|
| Rate for Payer: Cash Price |
$601.50
|
| Rate for Payer: Cigna Commercial |
$1,844.60
|
| Rate for Payer: Health EOS Commercial |
$1,784.45
|
| Rate for Payer: HFN Commercial |
$1,844.60
|
| Rate for Payer: Multiplan Commercial |
$1,604.00
|
| Rate for Payer: NAPHCARE Commercial |
$1,203.00
|
| Rate for Payer: Preferred Network Access Commercial |
$1,844.60
|
| Rate for Payer: Quartz Beloit One Network |
$982.45
|
| Rate for Payer: Quartz Commercial |
$1,203.00
|
| Rate for Payer: WEA Trust Commercial |
$1,102.75
|
| Rate for Payer: WPS Commercial |
$1,485.10
|
|
|
BALLOON CONQUEST 40 4MM X 4CM X 75CM X 5.8F X .035 CQF7544
|
Facility
OP
|
$2,005.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
6205004
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$561.40 |
| Max. Negotiated Rate |
$1,844.60 |
| Rate for Payer: Aetna Commercial |
$1,804.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,724.30
|
| Rate for Payer: Aetna Managed Medicare |
$561.40
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,303.25
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,002.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$962.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,062.65
|
| Rate for Payer: Cash Price |
$601.50
|
| Rate for Payer: Cigna Commercial |
$1,844.60
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,122.00
|
| Rate for Payer: Health EOS Commercial |
$1,784.45
|
| Rate for Payer: HFN Commercial |
$1,844.60
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,503.75
|
| Rate for Payer: Multiplan Commercial |
$1,604.00
|
| Rate for Payer: NAPHCARE Commercial |
$1,203.00
|
| Rate for Payer: Preferred Network Access Commercial |
$1,844.60
|
| Rate for Payer: Quartz Beloit One Network |
$982.45
|
| Rate for Payer: Quartz Commercial |
$1,303.25
|
| Rate for Payer: Quartz Medicare Advantage |
$1,203.00
|
| Rate for Payer: WEA Trust Commercial |
$1,102.75
|
| Rate for Payer: WPS Commercial |
$1,485.10
|
|
|
BALLOON CONQUEST 40 5MM X 2CM X 75CM X 5.8F X .035 CQF7552
|
Facility
IP
|
$2,005.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
6205006
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$982.45 |
| Max. Negotiated Rate |
$1,844.60 |
| Rate for Payer: Aetna Commercial |
$1,804.50
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,062.65
|
| Rate for Payer: Cash Price |
$601.50
|
| Rate for Payer: Cigna Commercial |
$1,844.60
|
| Rate for Payer: Health EOS Commercial |
$1,784.45
|
| Rate for Payer: HFN Commercial |
$1,844.60
|
| Rate for Payer: Multiplan Commercial |
$1,604.00
|
| Rate for Payer: NAPHCARE Commercial |
$1,203.00
|
| Rate for Payer: Preferred Network Access Commercial |
$1,844.60
|
| Rate for Payer: Quartz Beloit One Network |
$982.45
|
| Rate for Payer: Quartz Commercial |
$1,203.00
|
| Rate for Payer: WEA Trust Commercial |
$1,102.75
|
| Rate for Payer: WPS Commercial |
$1,485.10
|
|
|
BALLOON CONQUEST 40 5MM X 2CM X 75CM X 5.8F X .035 CQF7552
|
Facility
OP
|
$2,005.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
6205006
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$561.40 |
| Max. Negotiated Rate |
$1,844.60 |
| Rate for Payer: Aetna Commercial |
$1,804.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,724.30
|
| Rate for Payer: Aetna Managed Medicare |
$561.40
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,303.25
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,002.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$962.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,062.65
|
| Rate for Payer: Cash Price |
$601.50
|
| Rate for Payer: Cigna Commercial |
$1,844.60
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,122.00
|
| Rate for Payer: Health EOS Commercial |
$1,784.45
|
| Rate for Payer: HFN Commercial |
$1,844.60
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,503.75
|
| Rate for Payer: Multiplan Commercial |
$1,604.00
|
| Rate for Payer: NAPHCARE Commercial |
$1,203.00
|
| Rate for Payer: Preferred Network Access Commercial |
$1,844.60
|
| Rate for Payer: Quartz Beloit One Network |
$982.45
|
| Rate for Payer: Quartz Commercial |
$1,303.25
|
| Rate for Payer: Quartz Medicare Advantage |
$1,203.00
|
| Rate for Payer: WEA Trust Commercial |
$1,102.75
|
| Rate for Payer: WPS Commercial |
$1,485.10
|
|
|
BALLOON CONQUEST 40 5MM X 4CM X 75CM X 5.8F X .035 CQF7554
|
Facility
IP
|
$2,005.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
6205007
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$982.45 |
| Max. Negotiated Rate |
$1,844.60 |
| Rate for Payer: Aetna Commercial |
$1,804.50
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,062.65
|
| Rate for Payer: Cash Price |
$601.50
|
| Rate for Payer: Cigna Commercial |
$1,844.60
|
| Rate for Payer: Health EOS Commercial |
$1,784.45
|
| Rate for Payer: HFN Commercial |
$1,844.60
|
| Rate for Payer: Multiplan Commercial |
$1,604.00
|
| Rate for Payer: NAPHCARE Commercial |
$1,203.00
|
| Rate for Payer: Preferred Network Access Commercial |
$1,844.60
|
| Rate for Payer: Quartz Beloit One Network |
$982.45
|
| Rate for Payer: Quartz Commercial |
$1,203.00
|
| Rate for Payer: WEA Trust Commercial |
$1,102.75
|
| Rate for Payer: WPS Commercial |
$1,485.10
|
|
|
BALLOON CONQUEST 40 5MM X 4CM X 75CM X 5.8F X .035 CQF7554
|
Facility
OP
|
$2,005.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
6205007
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$561.40 |
| Max. Negotiated Rate |
$1,844.60 |
| Rate for Payer: Aetna Commercial |
$1,804.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,724.30
|
| Rate for Payer: Aetna Managed Medicare |
$561.40
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,303.25
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,002.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$962.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,062.65
|
| Rate for Payer: Cash Price |
$601.50
|
| Rate for Payer: Cigna Commercial |
$1,844.60
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,122.00
|
| Rate for Payer: Health EOS Commercial |
$1,784.45
|
| Rate for Payer: HFN Commercial |
$1,844.60
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,503.75
|
| Rate for Payer: Multiplan Commercial |
$1,604.00
|
| Rate for Payer: NAPHCARE Commercial |
$1,203.00
|
| Rate for Payer: Preferred Network Access Commercial |
$1,844.60
|
| Rate for Payer: Quartz Beloit One Network |
$982.45
|
| Rate for Payer: Quartz Commercial |
$1,303.25
|
| Rate for Payer: Quartz Medicare Advantage |
$1,203.00
|
| Rate for Payer: WEA Trust Commercial |
$1,102.75
|
| Rate for Payer: WPS Commercial |
$1,485.10
|
|
|
BALLOON CONQUEST 40 6MM X 2CM X 75CM X 5.8F X .035 CQF7562
|
Facility
OP
|
$2,005.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
6205008
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$561.40 |
| Max. Negotiated Rate |
$1,844.60 |
| Rate for Payer: Aetna Commercial |
$1,804.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,724.30
|
| Rate for Payer: Aetna Managed Medicare |
$561.40
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,303.25
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,002.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$962.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,062.65
|
| Rate for Payer: Cash Price |
$601.50
|
| Rate for Payer: Cigna Commercial |
$1,844.60
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,122.00
|
| Rate for Payer: Health EOS Commercial |
$1,784.45
|
| Rate for Payer: HFN Commercial |
$1,844.60
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,503.75
|
| Rate for Payer: Multiplan Commercial |
$1,604.00
|
| Rate for Payer: NAPHCARE Commercial |
$1,203.00
|
| Rate for Payer: Preferred Network Access Commercial |
$1,844.60
|
| Rate for Payer: Quartz Beloit One Network |
$982.45
|
| Rate for Payer: Quartz Commercial |
$1,303.25
|
| Rate for Payer: Quartz Medicare Advantage |
$1,203.00
|
| Rate for Payer: WEA Trust Commercial |
$1,102.75
|
| Rate for Payer: WPS Commercial |
$1,485.10
|
|
|
BALLOON CONQUEST 40 6MM X 2CM X 75CM X 5.8F X .035 CQF7562
|
Facility
IP
|
$2,005.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
6205008
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$982.45 |
| Max. Negotiated Rate |
$1,844.60 |
| Rate for Payer: Aetna Commercial |
$1,804.50
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,062.65
|
| Rate for Payer: Cash Price |
$601.50
|
| Rate for Payer: Cigna Commercial |
$1,844.60
|
| Rate for Payer: Health EOS Commercial |
$1,784.45
|
| Rate for Payer: HFN Commercial |
$1,844.60
|
| Rate for Payer: Multiplan Commercial |
$1,604.00
|
| Rate for Payer: NAPHCARE Commercial |
$1,203.00
|
| Rate for Payer: Preferred Network Access Commercial |
$1,844.60
|
| Rate for Payer: Quartz Beloit One Network |
$982.45
|
| Rate for Payer: Quartz Commercial |
$1,203.00
|
| Rate for Payer: WEA Trust Commercial |
$1,102.75
|
| Rate for Payer: WPS Commercial |
$1,485.10
|
|
|
BALLOON CONQUEST 40 6MM X 4CM X 75CM X 6F X .035 CQF7564
|
Facility
IP
|
$2,005.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
6205010
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$982.45 |
| Max. Negotiated Rate |
$1,844.60 |
| Rate for Payer: Aetna Commercial |
$1,804.50
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,062.65
|
| Rate for Payer: Cash Price |
$601.50
|
| Rate for Payer: Cigna Commercial |
$1,844.60
|
| Rate for Payer: Health EOS Commercial |
$1,784.45
|
| Rate for Payer: HFN Commercial |
$1,844.60
|
| Rate for Payer: Multiplan Commercial |
$1,604.00
|
| Rate for Payer: NAPHCARE Commercial |
$1,203.00
|
| Rate for Payer: Preferred Network Access Commercial |
$1,844.60
|
| Rate for Payer: Quartz Beloit One Network |
$982.45
|
| Rate for Payer: Quartz Commercial |
$1,203.00
|
| Rate for Payer: WEA Trust Commercial |
$1,102.75
|
| Rate for Payer: WPS Commercial |
$1,485.10
|
|
|
BALLOON CONQUEST 40 6MM X 4CM X 75CM X 6F X .035 CQF7564
|
Facility
OP
|
$2,005.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
6205010
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$561.40 |
| Max. Negotiated Rate |
$1,844.60 |
| Rate for Payer: Aetna Commercial |
$1,804.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,724.30
|
| Rate for Payer: Aetna Managed Medicare |
$561.40
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,303.25
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,002.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$962.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,062.65
|
| Rate for Payer: Cash Price |
$601.50
|
| Rate for Payer: Cigna Commercial |
$1,844.60
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,122.00
|
| Rate for Payer: Health EOS Commercial |
$1,784.45
|
| Rate for Payer: HFN Commercial |
$1,844.60
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,503.75
|
| Rate for Payer: Multiplan Commercial |
$1,604.00
|
| Rate for Payer: NAPHCARE Commercial |
$1,203.00
|
| Rate for Payer: Preferred Network Access Commercial |
$1,844.60
|
| Rate for Payer: Quartz Beloit One Network |
$982.45
|
| Rate for Payer: Quartz Commercial |
$1,303.25
|
| Rate for Payer: Quartz Medicare Advantage |
$1,203.00
|
| Rate for Payer: WEA Trust Commercial |
$1,102.75
|
| Rate for Payer: WPS Commercial |
$1,485.10
|
|
|
BALLOON CONQUEST 40 6MM X 8CM X 75CM X 6F X .035 CQF7568
|
Facility
OP
|
$2,005.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
6206958
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$561.40 |
| Max. Negotiated Rate |
$1,844.60 |
| Rate for Payer: Aetna Commercial |
$1,804.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,724.30
|
| Rate for Payer: Aetna Managed Medicare |
$561.40
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,303.25
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,002.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$962.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,062.65
|
| Rate for Payer: Cash Price |
$601.50
|
| Rate for Payer: Cigna Commercial |
$1,844.60
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,122.00
|
| Rate for Payer: Health EOS Commercial |
$1,784.45
|
| Rate for Payer: HFN Commercial |
$1,844.60
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,503.75
|
| Rate for Payer: Multiplan Commercial |
$1,604.00
|
| Rate for Payer: NAPHCARE Commercial |
$1,203.00
|
| Rate for Payer: Preferred Network Access Commercial |
$1,844.60
|
| Rate for Payer: Quartz Beloit One Network |
$982.45
|
| Rate for Payer: Quartz Commercial |
$1,303.25
|
| Rate for Payer: Quartz Medicare Advantage |
$1,203.00
|
| Rate for Payer: WEA Trust Commercial |
$1,102.75
|
| Rate for Payer: WPS Commercial |
$1,485.10
|
|
|
BALLOON CONQUEST 40 6MM X 8CM X 75CM X 6F X .035 CQF7568
|
Facility
IP
|
$2,005.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
6206958
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$982.45 |
| Max. Negotiated Rate |
$1,844.60 |
| Rate for Payer: Aetna Commercial |
$1,804.50
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,062.65
|
| Rate for Payer: Cash Price |
$601.50
|
| Rate for Payer: Cigna Commercial |
$1,844.60
|
| Rate for Payer: Health EOS Commercial |
$1,784.45
|
| Rate for Payer: HFN Commercial |
$1,844.60
|
| Rate for Payer: Multiplan Commercial |
$1,604.00
|
| Rate for Payer: NAPHCARE Commercial |
$1,203.00
|
| Rate for Payer: Preferred Network Access Commercial |
$1,844.60
|
| Rate for Payer: Quartz Beloit One Network |
$982.45
|
| Rate for Payer: Quartz Commercial |
$1,203.00
|
| Rate for Payer: WEA Trust Commercial |
$1,102.75
|
| Rate for Payer: WPS Commercial |
$1,485.10
|
|
|
BALLOON CONQUEST 40 7MM X 2CM X 75CM X 5.8F X .035 CQF7572
|
Facility
IP
|
$2,005.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
6206957
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$982.45 |
| Max. Negotiated Rate |
$1,844.60 |
| Rate for Payer: Aetna Commercial |
$1,804.50
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,062.65
|
| Rate for Payer: Cash Price |
$601.50
|
| Rate for Payer: Cigna Commercial |
$1,844.60
|
| Rate for Payer: Health EOS Commercial |
$1,784.45
|
| Rate for Payer: HFN Commercial |
$1,844.60
|
| Rate for Payer: Multiplan Commercial |
$1,604.00
|
| Rate for Payer: NAPHCARE Commercial |
$1,203.00
|
| Rate for Payer: Preferred Network Access Commercial |
$1,844.60
|
| Rate for Payer: Quartz Beloit One Network |
$982.45
|
| Rate for Payer: Quartz Commercial |
$1,203.00
|
| Rate for Payer: WEA Trust Commercial |
$1,102.75
|
| Rate for Payer: WPS Commercial |
$1,485.10
|
|
