|
BALLOON 9.0 X40 AB35W09040080
|
Facility
|
IP
|
$1,708.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
2972513
|
|
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: Aetna Gatekeeper/Not Gatekeeper |
$1,468.88
|
| 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 9.0 X40 AB35W09040080
|
Facility
|
OP
|
$1,708.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
2972513
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$478.24 |
| Max. Negotiated Rate |
$6,832.00 |
| 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: The Alliance Commercial |
$6,832.00
|
| Rate for Payer: WEA Trust Commercial |
$939.40
|
| Rate for Payer: WPS Commercial |
$1,265.12
|
|
|
BALLOON 9.0 X 40MM EVERCROSS
|
Facility
|
IP
|
$1,708.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
2972523
|
|
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: Aetna Gatekeeper/Not Gatekeeper |
$1,468.88
|
| 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 9.0 X 40MM EVERCROSS
|
Facility
|
OP
|
$1,708.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
2972523
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$478.24 |
| Max. Negotiated Rate |
$6,832.00 |
| 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: The Alliance Commercial |
$6,832.00
|
| Rate for Payer: WEA Trust Commercial |
$939.40
|
| Rate for Payer: WPS Commercial |
$1,265.12
|
|
|
BALLOON 9 X 60mm AB35W09060080
|
Facility
|
IP
|
$1,708.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
2972491
|
|
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: Aetna Gatekeeper/Not Gatekeeper |
$1,468.88
|
| 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 9 X 60mm AB35W09060080
|
Facility
|
OP
|
$1,708.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
2972491
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$478.24 |
| Max. Negotiated Rate |
$6,832.00 |
| 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: The Alliance Commercial |
$6,832.00
|
| Rate for Payer: WEA Trust Commercial |
$939.40
|
| Rate for Payer: WPS Commercial |
$1,265.12
|
|
|
BALLOON ATLAS 20MM X 4CM X 75CM X 9F X.035 AT75204
|
Facility
|
OP
|
$2,724.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
6204993
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$762.72 |
| Max. Negotiated Rate |
$10,896.00 |
| Rate for Payer: Aetna Commercial |
$2,451.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,342.64
|
| Rate for Payer: Aetna Managed Medicare |
$762.72
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,770.60
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,362.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,307.52
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,443.72
|
| Rate for Payer: Cash Price |
$817.20
|
| Rate for Payer: Cigna Commercial |
$2,506.08
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,524.35
|
| Rate for Payer: Health EOS Commercial |
$2,424.36
|
| Rate for Payer: HFN Commercial |
$2,506.08
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,043.00
|
| Rate for Payer: Multiplan Commercial |
$2,179.20
|
| Rate for Payer: NAPHCARE Commercial |
$1,634.40
|
| Rate for Payer: Preferred Network Access Commercial |
$2,506.08
|
| Rate for Payer: Quartz Beloit One Network |
$1,334.76
|
| Rate for Payer: Quartz Commercial |
$1,770.60
|
| Rate for Payer: Quartz Medicare Advantage |
$1,634.40
|
| Rate for Payer: The Alliance Commercial |
$10,896.00
|
| Rate for Payer: WEA Trust Commercial |
$1,498.20
|
| Rate for Payer: WPS Commercial |
$2,017.67
|
|
|
BALLOON ATLAS 20MM X 4CM X 75CM X 9F X.035 AT75204
|
Facility
|
IP
|
$2,724.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
6204993
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,334.76 |
| Max. Negotiated Rate |
$2,506.08 |
| Rate for Payer: Aetna Commercial |
$2,451.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,342.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,443.72
|
| Rate for Payer: Cash Price |
$817.20
|
| Rate for Payer: Cigna Commercial |
$2,506.08
|
| Rate for Payer: Health EOS Commercial |
$2,424.36
|
| Rate for Payer: HFN Commercial |
$2,506.08
|
| Rate for Payer: Multiplan Commercial |
$2,179.20
|
| Rate for Payer: NAPHCARE Commercial |
$1,634.40
|
| Rate for Payer: Preferred Network Access Commercial |
$2,506.08
|
| Rate for Payer: Quartz Beloit One Network |
$1,334.76
|
| Rate for Payer: Quartz Commercial |
$1,634.40
|
| Rate for Payer: WEA Trust Commercial |
$1,498.20
|
| Rate for Payer: WPS Commercial |
$2,017.67
|
|
|
BALLOON ATLAS GOLD 14MM X 4CM X 80CM X 8F X.035 ATG80144
|
Facility
|
OP
|
$2,743.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
6204995
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$768.04 |
| Max. Negotiated Rate |
$10,972.00 |
| Rate for Payer: Aetna Commercial |
$2,468.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,358.98
|
| Rate for Payer: Aetna Managed Medicare |
$768.04
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,782.95
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,371.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,316.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,453.79
|
| Rate for Payer: Cash Price |
$822.90
|
| Rate for Payer: Cigna Commercial |
$2,523.56
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,534.98
|
| Rate for Payer: Health EOS Commercial |
$2,441.27
|
| Rate for Payer: HFN Commercial |
$2,523.56
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,057.25
|
| Rate for Payer: Multiplan Commercial |
$2,194.40
|
| Rate for Payer: NAPHCARE Commercial |
$1,645.80
|
| Rate for Payer: Preferred Network Access Commercial |
$2,523.56
|
| Rate for Payer: Quartz Beloit One Network |
$1,344.07
|
| Rate for Payer: Quartz Commercial |
$1,782.95
|
| Rate for Payer: Quartz Medicare Advantage |
$1,645.80
|
| Rate for Payer: The Alliance Commercial |
$10,972.00
|
| Rate for Payer: WEA Trust Commercial |
$1,508.65
|
| Rate for Payer: WPS Commercial |
$2,031.74
|
|
|
BALLOON ATLAS GOLD 14MM X 4CM X 80CM X 8F X.035 ATG80144
|
Facility
|
IP
|
$2,743.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
6204995
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,344.07 |
| Max. Negotiated Rate |
$2,523.56 |
| Rate for Payer: Aetna Commercial |
$2,468.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,358.98
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,453.79
|
| Rate for Payer: Cash Price |
$822.90
|
| Rate for Payer: Cigna Commercial |
$2,523.56
|
| Rate for Payer: Health EOS Commercial |
$2,441.27
|
| Rate for Payer: HFN Commercial |
$2,523.56
|
| Rate for Payer: Multiplan Commercial |
$2,194.40
|
| Rate for Payer: NAPHCARE Commercial |
$1,645.80
|
| Rate for Payer: Preferred Network Access Commercial |
$2,523.56
|
| Rate for Payer: Quartz Beloit One Network |
$1,344.07
|
| Rate for Payer: Quartz Commercial |
$1,645.80
|
| Rate for Payer: WEA Trust Commercial |
$1,508.65
|
| Rate for Payer: WPS Commercial |
$2,031.74
|
|
|
BALLOON ATLAS GOLD 16MM X 4CM X 80CM X 6.5F X .035 ATG80164
|
Facility
|
OP
|
$2,743.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
6204996
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$768.04 |
| Max. Negotiated Rate |
$10,972.00 |
| Rate for Payer: Aetna Commercial |
$2,468.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,358.98
|
| Rate for Payer: Aetna Managed Medicare |
$768.04
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,782.95
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,371.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,316.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,453.79
|
| Rate for Payer: Cash Price |
$822.90
|
| Rate for Payer: Cigna Commercial |
$2,523.56
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,534.98
|
| Rate for Payer: Health EOS Commercial |
$2,441.27
|
| Rate for Payer: HFN Commercial |
$2,523.56
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,057.25
|
| Rate for Payer: Multiplan Commercial |
$2,194.40
|
| Rate for Payer: NAPHCARE Commercial |
$1,645.80
|
| Rate for Payer: Preferred Network Access Commercial |
$2,523.56
|
| Rate for Payer: Quartz Beloit One Network |
$1,344.07
|
| Rate for Payer: Quartz Commercial |
$1,782.95
|
| Rate for Payer: Quartz Medicare Advantage |
$1,645.80
|
| Rate for Payer: The Alliance Commercial |
$10,972.00
|
| Rate for Payer: WEA Trust Commercial |
$1,508.65
|
| Rate for Payer: WPS Commercial |
$2,031.74
|
|
|
BALLOON ATLAS GOLD 16MM X 4CM X 80CM X 6.5F X .035 ATG80164
|
Facility
|
IP
|
$2,743.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
6204996
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,344.07 |
| Max. Negotiated Rate |
$2,523.56 |
| Rate for Payer: Aetna Commercial |
$2,468.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,358.98
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,453.79
|
| Rate for Payer: Cash Price |
$822.90
|
| Rate for Payer: Cigna Commercial |
$2,523.56
|
| Rate for Payer: Health EOS Commercial |
$2,441.27
|
| Rate for Payer: HFN Commercial |
$2,523.56
|
| Rate for Payer: Multiplan Commercial |
$2,194.40
|
| Rate for Payer: NAPHCARE Commercial |
$1,645.80
|
| Rate for Payer: Preferred Network Access Commercial |
$2,523.56
|
| Rate for Payer: Quartz Beloit One Network |
$1,344.07
|
| Rate for Payer: Quartz Commercial |
$1,645.80
|
| Rate for Payer: WEA Trust Commercial |
$1,508.65
|
| Rate for Payer: WPS Commercial |
$2,031.74
|
|
|
BALLOON ATLAS GOLD 18MM X 4CM X 80CM X 8F X.035 ATG80184
|
Facility
|
IP
|
$2,743.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
6204994
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,344.07 |
| Max. Negotiated Rate |
$2,523.56 |
| Rate for Payer: Aetna Commercial |
$2,468.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,358.98
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,453.79
|
| Rate for Payer: Cash Price |
$822.90
|
| Rate for Payer: Cigna Commercial |
$2,523.56
|
| Rate for Payer: Health EOS Commercial |
$2,441.27
|
| Rate for Payer: HFN Commercial |
$2,523.56
|
| Rate for Payer: Multiplan Commercial |
$2,194.40
|
| Rate for Payer: NAPHCARE Commercial |
$1,645.80
|
| Rate for Payer: Preferred Network Access Commercial |
$2,523.56
|
| Rate for Payer: Quartz Beloit One Network |
$1,344.07
|
| Rate for Payer: Quartz Commercial |
$1,645.80
|
| Rate for Payer: WEA Trust Commercial |
$1,508.65
|
| Rate for Payer: WPS Commercial |
$2,031.74
|
|
|
BALLOON ATLAS GOLD 18MM X 4CM X 80CM X 8F X.035 ATG80184
|
Facility
|
OP
|
$2,743.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
6204994
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$768.04 |
| Max. Negotiated Rate |
$10,972.00 |
| Rate for Payer: Aetna Commercial |
$2,468.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,358.98
|
| Rate for Payer: Aetna Managed Medicare |
$768.04
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,782.95
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,371.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,316.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,453.79
|
| Rate for Payer: Cash Price |
$822.90
|
| Rate for Payer: Cigna Commercial |
$2,523.56
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,534.98
|
| Rate for Payer: Health EOS Commercial |
$2,441.27
|
| Rate for Payer: HFN Commercial |
$2,523.56
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,057.25
|
| Rate for Payer: Multiplan Commercial |
$2,194.40
|
| Rate for Payer: NAPHCARE Commercial |
$1,645.80
|
| Rate for Payer: Preferred Network Access Commercial |
$2,523.56
|
| Rate for Payer: Quartz Beloit One Network |
$1,344.07
|
| Rate for Payer: Quartz Commercial |
$1,782.95
|
| Rate for Payer: Quartz Medicare Advantage |
$1,645.80
|
| Rate for Payer: The Alliance Commercial |
$10,972.00
|
| Rate for Payer: WEA Trust Commercial |
$1,508.65
|
| Rate for Payer: WPS Commercial |
$2,031.74
|
|
|
BALLOON ATLAS GOLD 20MM X 4CM X 80CM X 9F X .035 ATG80204
|
Facility
|
IP
|
$2,837.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
6204997
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,390.13 |
| Max. Negotiated Rate |
$2,610.04 |
| Rate for Payer: Aetna Commercial |
$2,553.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,439.82
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,503.61
|
| Rate for Payer: Cash Price |
$851.10
|
| Rate for Payer: Cigna Commercial |
$2,610.04
|
| Rate for Payer: Health EOS Commercial |
$2,524.93
|
| Rate for Payer: HFN Commercial |
$2,610.04
|
| Rate for Payer: Multiplan Commercial |
$2,269.60
|
| Rate for Payer: NAPHCARE Commercial |
$1,702.20
|
| Rate for Payer: Preferred Network Access Commercial |
$2,610.04
|
| Rate for Payer: Quartz Beloit One Network |
$1,390.13
|
| Rate for Payer: Quartz Commercial |
$1,702.20
|
| Rate for Payer: WEA Trust Commercial |
$1,560.35
|
| Rate for Payer: WPS Commercial |
$2,101.37
|
|
|
BALLOON ATLAS GOLD 20MM X 4CM X 80CM X 9F X .035 ATG80204
|
Facility
|
OP
|
$2,837.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
6204997
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$794.36 |
| Max. Negotiated Rate |
$11,348.00 |
| Rate for Payer: Aetna Commercial |
$2,553.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,439.82
|
| Rate for Payer: Aetna Managed Medicare |
$794.36
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,844.05
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,418.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,361.76
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,503.61
|
| Rate for Payer: Cash Price |
$851.10
|
| Rate for Payer: Cigna Commercial |
$2,610.04
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,587.59
|
| Rate for Payer: Health EOS Commercial |
$2,524.93
|
| Rate for Payer: HFN Commercial |
$2,610.04
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,127.75
|
| Rate for Payer: Multiplan Commercial |
$2,269.60
|
| Rate for Payer: NAPHCARE Commercial |
$1,702.20
|
| Rate for Payer: Preferred Network Access Commercial |
$2,610.04
|
| Rate for Payer: Quartz Beloit One Network |
$1,390.13
|
| Rate for Payer: Quartz Commercial |
$1,844.05
|
| Rate for Payer: Quartz Medicare Advantage |
$1,702.20
|
| Rate for Payer: The Alliance Commercial |
$11,348.00
|
| Rate for Payer: WEA Trust Commercial |
$1,560.35
|
| Rate for Payer: WPS Commercial |
$2,101.37
|
|
|
BALLOON ATLAS PTA 16MM X 4 AT75164
|
Facility
|
IP
|
$2,639.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
5459319
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,293.11 |
| Max. Negotiated Rate |
$2,427.88 |
| Rate for Payer: Aetna Commercial |
$2,375.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,269.54
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,398.67
|
| Rate for Payer: Cash Price |
$791.70
|
| Rate for Payer: Cigna Commercial |
$2,427.88
|
| Rate for Payer: Health EOS Commercial |
$2,348.71
|
| Rate for Payer: HFN Commercial |
$2,427.88
|
| Rate for Payer: Multiplan Commercial |
$2,111.20
|
| Rate for Payer: NAPHCARE Commercial |
$1,583.40
|
| Rate for Payer: Preferred Network Access Commercial |
$2,427.88
|
| Rate for Payer: Quartz Beloit One Network |
$1,293.11
|
| Rate for Payer: Quartz Commercial |
$1,583.40
|
| Rate for Payer: WEA Trust Commercial |
$1,451.45
|
| Rate for Payer: WPS Commercial |
$1,954.71
|
|
|
BALLOON ATLAS PTA 16MM X 4 AT75164
|
Facility
|
OP
|
$2,639.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
5459319
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$738.92 |
| Max. Negotiated Rate |
$10,556.00 |
| Rate for Payer: Aetna Commercial |
$2,375.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,269.54
|
| Rate for Payer: Aetna Managed Medicare |
$738.92
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,715.35
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,319.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,266.72
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,398.67
|
| Rate for Payer: Cash Price |
$791.70
|
| Rate for Payer: Cigna Commercial |
$2,427.88
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,476.78
|
| Rate for Payer: Health EOS Commercial |
$2,348.71
|
| Rate for Payer: HFN Commercial |
$2,427.88
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,979.25
|
| Rate for Payer: Multiplan Commercial |
$2,111.20
|
| Rate for Payer: NAPHCARE Commercial |
$1,583.40
|
| Rate for Payer: Preferred Network Access Commercial |
$2,427.88
|
| Rate for Payer: Quartz Beloit One Network |
$1,293.11
|
| Rate for Payer: Quartz Commercial |
$1,715.35
|
| Rate for Payer: Quartz Medicare Advantage |
$1,583.40
|
| Rate for Payer: The Alliance Commercial |
$10,556.00
|
| Rate for Payer: WEA Trust Commercial |
$1,451.45
|
| Rate for Payer: WPS Commercial |
$1,954.71
|
|
|
BALLOON ATLAS PTA 18MM X 4 AT75184
|
Facility
|
IP
|
$2,639.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
5459318
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,293.11 |
| Max. Negotiated Rate |
$2,427.88 |
| Rate for Payer: Aetna Commercial |
$2,375.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,269.54
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,398.67
|
| Rate for Payer: Cash Price |
$791.70
|
| Rate for Payer: Cigna Commercial |
$2,427.88
|
| Rate for Payer: Health EOS Commercial |
$2,348.71
|
| Rate for Payer: HFN Commercial |
$2,427.88
|
| Rate for Payer: Multiplan Commercial |
$2,111.20
|
| Rate for Payer: NAPHCARE Commercial |
$1,583.40
|
| Rate for Payer: Preferred Network Access Commercial |
$2,427.88
|
| Rate for Payer: Quartz Beloit One Network |
$1,293.11
|
| Rate for Payer: Quartz Commercial |
$1,583.40
|
| Rate for Payer: WEA Trust Commercial |
$1,451.45
|
| Rate for Payer: WPS Commercial |
$1,954.71
|
|
|
BALLOON ATLAS PTA 18MM X 4 AT75184
|
Facility
|
OP
|
$2,639.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
5459318
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$738.92 |
| Max. Negotiated Rate |
$10,556.00 |
| Rate for Payer: Aetna Commercial |
$2,375.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,269.54
|
| Rate for Payer: Aetna Managed Medicare |
$738.92
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,715.35
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,319.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,266.72
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,398.67
|
| Rate for Payer: Cash Price |
$791.70
|
| Rate for Payer: Cigna Commercial |
$2,427.88
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,476.78
|
| Rate for Payer: Health EOS Commercial |
$2,348.71
|
| Rate for Payer: HFN Commercial |
$2,427.88
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,979.25
|
| Rate for Payer: Multiplan Commercial |
$2,111.20
|
| Rate for Payer: NAPHCARE Commercial |
$1,583.40
|
| Rate for Payer: Preferred Network Access Commercial |
$2,427.88
|
| Rate for Payer: Quartz Beloit One Network |
$1,293.11
|
| Rate for Payer: Quartz Commercial |
$1,715.35
|
| Rate for Payer: Quartz Medicare Advantage |
$1,583.40
|
| Rate for Payer: The Alliance Commercial |
$10,556.00
|
| Rate for Payer: WEA Trust Commercial |
$1,451.45
|
| Rate for Payer: WPS Commercial |
$1,954.71
|
|
|
BALLOON AVIATOR PTA 4 X 2 424-4020W
|
Facility
|
IP
|
$1,708.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
3107471
|
|
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: Aetna Gatekeeper/Not Gatekeeper |
$1,468.88
|
| 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 AVIATOR PTA 4 X 2 424-4020W
|
Facility
|
OP
|
$1,708.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
3107471
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$478.24 |
| Max. Negotiated Rate |
$6,832.00 |
| 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: The Alliance Commercial |
$6,832.00
|
| Rate for Payer: WEA Trust Commercial |
$939.40
|
| Rate for Payer: WPS Commercial |
$1,265.12
|
|
|
BALLOON AVIATOR PTA 6 X 2 #424-6020W
|
Facility
|
IP
|
$1,708.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
3107473
|
|
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: Aetna Gatekeeper/Not Gatekeeper |
$1,468.88
|
| 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 AVIATOR PTA 6 X 2 #424-6020W
|
Facility
|
OP
|
$1,708.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
3107473
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$478.24 |
| Max. Negotiated Rate |
$6,832.00 |
| 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: The Alliance Commercial |
$6,832.00
|
| Rate for Payer: WEA Trust Commercial |
$939.40
|
| Rate for Payer: WPS Commercial |
$1,265.12
|
|
|
BALLOON AVIATOR PTA 7 X 2 424-7020W
|
Facility
|
IP
|
$1,708.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
3107474
|
|
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: Aetna Gatekeeper/Not Gatekeeper |
$1,468.88
|
| 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
|
|
