|
BALLOON AVIATOR PTA 7 X 2 424-7020W
|
Facility
|
OP
|
$1,708.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
3107474
|
|
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 CATH ASCEND 4X4 G32834
|
Facility
|
OP
|
$2,698.00
|
|
| Hospital Charge Code |
2969465
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$755.44 |
| Max. Negotiated Rate |
$10,792.00 |
| Rate for Payer: Aetna Commercial |
$2,428.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,320.28
|
| Rate for Payer: Aetna Managed Medicare |
$755.44
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,753.70
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,349.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,295.04
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,429.94
|
| Rate for Payer: Cash Price |
$809.40
|
| Rate for Payer: Cigna Commercial |
$2,482.16
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,509.80
|
| Rate for Payer: Health EOS Commercial |
$2,401.22
|
| Rate for Payer: HFN Commercial |
$2,482.16
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,023.50
|
| Rate for Payer: Multiplan Commercial |
$2,158.40
|
| Rate for Payer: NAPHCARE Commercial |
$1,618.80
|
| Rate for Payer: Preferred Network Access Commercial |
$2,482.16
|
| Rate for Payer: Quartz Beloit One Network |
$1,322.02
|
| Rate for Payer: Quartz Commercial |
$1,753.70
|
| Rate for Payer: Quartz Medicare Advantage |
$1,618.80
|
| Rate for Payer: The Alliance Commercial |
$10,792.00
|
| Rate for Payer: WEA Trust Commercial |
$1,483.90
|
| Rate for Payer: WPS Commercial |
$1,998.41
|
|
|
BALLOON CATH ASCEND 4X4 G32834
|
Facility
|
IP
|
$2,698.00
|
|
| Hospital Charge Code |
2969465
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,322.02 |
| Max. Negotiated Rate |
$2,482.16 |
| Rate for Payer: Aetna Commercial |
$2,428.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,320.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,429.94
|
| Rate for Payer: Cash Price |
$809.40
|
| Rate for Payer: Cigna Commercial |
$2,482.16
|
| Rate for Payer: Health EOS Commercial |
$2,401.22
|
| Rate for Payer: HFN Commercial |
$2,482.16
|
| Rate for Payer: Multiplan Commercial |
$2,158.40
|
| Rate for Payer: NAPHCARE Commercial |
$1,618.80
|
| Rate for Payer: Preferred Network Access Commercial |
$2,482.16
|
| Rate for Payer: Quartz Beloit One Network |
$1,322.02
|
| Rate for Payer: Quartz Commercial |
$1,618.80
|
| Rate for Payer: WEA Trust Commercial |
$1,483.90
|
| Rate for Payer: WPS Commercial |
$1,998.41
|
|
|
BALLOON CATH ASCEND 6X4 G32840
|
Facility
|
IP
|
$2,958.00
|
|
| Hospital Charge Code |
2965854
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,449.42 |
| Max. Negotiated Rate |
$2,721.36 |
| Rate for Payer: Aetna Commercial |
$2,662.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,543.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,567.74
|
| Rate for Payer: Cash Price |
$887.40
|
| Rate for Payer: Cigna Commercial |
$2,721.36
|
| Rate for Payer: Health EOS Commercial |
$2,632.62
|
| Rate for Payer: HFN Commercial |
$2,721.36
|
| Rate for Payer: Multiplan Commercial |
$2,366.40
|
| Rate for Payer: NAPHCARE Commercial |
$1,774.80
|
| Rate for Payer: Preferred Network Access Commercial |
$2,721.36
|
| Rate for Payer: Quartz Beloit One Network |
$1,449.42
|
| Rate for Payer: Quartz Commercial |
$1,774.80
|
| Rate for Payer: WEA Trust Commercial |
$1,626.90
|
| Rate for Payer: WPS Commercial |
$2,190.99
|
|
|
BALLOON CATH ASCEND 6X4 G32840
|
Facility
|
OP
|
$2,958.00
|
|
| Hospital Charge Code |
2965854
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$828.24 |
| Max. Negotiated Rate |
$11,832.00 |
| Rate for Payer: Aetna Commercial |
$2,662.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,543.88
|
| Rate for Payer: Aetna Managed Medicare |
$828.24
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,922.70
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,479.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,419.84
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,567.74
|
| Rate for Payer: Cash Price |
$887.40
|
| Rate for Payer: Cigna Commercial |
$2,721.36
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,655.30
|
| Rate for Payer: Health EOS Commercial |
$2,632.62
|
| Rate for Payer: HFN Commercial |
$2,721.36
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,218.50
|
| Rate for Payer: Multiplan Commercial |
$2,366.40
|
| Rate for Payer: NAPHCARE Commercial |
$1,774.80
|
| Rate for Payer: Preferred Network Access Commercial |
$2,721.36
|
| Rate for Payer: Quartz Beloit One Network |
$1,449.42
|
| Rate for Payer: Quartz Commercial |
$1,922.70
|
| Rate for Payer: Quartz Medicare Advantage |
$1,774.80
|
| Rate for Payer: The Alliance Commercial |
$11,832.00
|
| Rate for Payer: WEA Trust Commercial |
$1,626.90
|
| Rate for Payer: WPS Commercial |
$2,190.99
|
|
|
BALLOON CATHETER NEPHROMAX HIGH PRESSURE 24FR X 12CM M0062101400
|
Facility
|
OP
|
$2,905.00
|
|
|
Service Code
|
HCPCS C1726
|
| Hospital Charge Code |
5306863
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$813.40 |
| Max. Negotiated Rate |
$11,620.00 |
| Rate for Payer: Aetna Commercial |
$2,614.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,498.30
|
| Rate for Payer: Aetna Managed Medicare |
$813.40
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,888.25
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,452.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,394.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,539.65
|
| Rate for Payer: Cash Price |
$871.50
|
| Rate for Payer: Cigna Commercial |
$2,672.60
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,625.64
|
| Rate for Payer: Health EOS Commercial |
$2,585.45
|
| Rate for Payer: HFN Commercial |
$2,672.60
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,178.75
|
| Rate for Payer: Multiplan Commercial |
$2,324.00
|
| Rate for Payer: NAPHCARE Commercial |
$1,743.00
|
| Rate for Payer: Preferred Network Access Commercial |
$2,672.60
|
| Rate for Payer: Quartz Beloit One Network |
$1,423.45
|
| Rate for Payer: Quartz Commercial |
$1,888.25
|
| Rate for Payer: Quartz Medicare Advantage |
$1,743.00
|
| Rate for Payer: The Alliance Commercial |
$11,620.00
|
| Rate for Payer: WEA Trust Commercial |
$1,597.75
|
| Rate for Payer: WPS Commercial |
$2,151.73
|
|
|
BALLOON CATHETER NEPHROMAX HIGH PRESSURE 24FR X 12CM M0062101400
|
Facility
|
IP
|
$2,905.00
|
|
|
Service Code
|
HCPCS C1726
|
| Hospital Charge Code |
5306863
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,423.45 |
| Max. Negotiated Rate |
$2,672.60 |
| Rate for Payer: Aetna Commercial |
$2,614.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,498.30
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,539.65
|
| Rate for Payer: Cash Price |
$871.50
|
| Rate for Payer: Cigna Commercial |
$2,672.60
|
| Rate for Payer: Health EOS Commercial |
$2,585.45
|
| Rate for Payer: HFN Commercial |
$2,672.60
|
| Rate for Payer: Multiplan Commercial |
$2,324.00
|
| Rate for Payer: NAPHCARE Commercial |
$1,743.00
|
| Rate for Payer: Preferred Network Access Commercial |
$2,672.60
|
| Rate for Payer: Quartz Beloit One Network |
$1,423.45
|
| Rate for Payer: Quartz Commercial |
$1,743.00
|
| Rate for Payer: WEA Trust Commercial |
$1,597.75
|
| Rate for Payer: WPS Commercial |
$2,151.73
|
|
|
BALLOON CATHETER NEPHROMAX HIGH PRESSURE 30FR X 12CM M0062101170
|
Facility
|
IP
|
$2,742.00
|
|
|
Service Code
|
HCPCS C1726
|
| Hospital Charge Code |
5384707
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,343.58 |
| Max. Negotiated Rate |
$2,522.64 |
| Rate for Payer: Aetna Commercial |
$2,467.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,358.12
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,453.26
|
| Rate for Payer: Cash Price |
$822.60
|
| Rate for Payer: Cigna Commercial |
$2,522.64
|
| Rate for Payer: Health EOS Commercial |
$2,440.38
|
| Rate for Payer: HFN Commercial |
$2,522.64
|
| Rate for Payer: Multiplan Commercial |
$2,193.60
|
| Rate for Payer: NAPHCARE Commercial |
$1,645.20
|
| Rate for Payer: Preferred Network Access Commercial |
$2,522.64
|
| Rate for Payer: Quartz Beloit One Network |
$1,343.58
|
| Rate for Payer: Quartz Commercial |
$1,645.20
|
| Rate for Payer: WEA Trust Commercial |
$1,508.10
|
| Rate for Payer: WPS Commercial |
$2,031.00
|
|
|
BALLOON CATHETER NEPHROMAX HIGH PRESSURE 30FR X 12CM M0062101170
|
Facility
|
OP
|
$2,742.00
|
|
|
Service Code
|
HCPCS C1726
|
| Hospital Charge Code |
5384707
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$767.76 |
| Max. Negotiated Rate |
$10,968.00 |
| Rate for Payer: Aetna Commercial |
$2,467.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,358.12
|
| Rate for Payer: Aetna Managed Medicare |
$767.76
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,782.30
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,371.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,316.16
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,453.26
|
| Rate for Payer: Cash Price |
$822.60
|
| Rate for Payer: Cigna Commercial |
$2,522.64
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,534.42
|
| Rate for Payer: Health EOS Commercial |
$2,440.38
|
| Rate for Payer: HFN Commercial |
$2,522.64
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,056.50
|
| Rate for Payer: Multiplan Commercial |
$2,193.60
|
| Rate for Payer: NAPHCARE Commercial |
$1,645.20
|
| Rate for Payer: Preferred Network Access Commercial |
$2,522.64
|
| Rate for Payer: Quartz Beloit One Network |
$1,343.58
|
| Rate for Payer: Quartz Commercial |
$1,782.30
|
| Rate for Payer: Quartz Medicare Advantage |
$1,645.20
|
| Rate for Payer: The Alliance Commercial |
$10,968.00
|
| Rate for Payer: WEA Trust Commercial |
$1,508.10
|
| Rate for Payer: WPS Commercial |
$2,031.00
|
|
|
BALLOON CATHETER NEPHROMAX HIGH PRESSURE 30FR X 17CM M0062101620
|
Facility
|
OP
|
$3,279.00
|
|
|
Service Code
|
HCPCS C1726
|
| Hospital Charge Code |
5415203
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$918.12 |
| Max. Negotiated Rate |
$13,116.00 |
| Rate for Payer: Aetna Commercial |
$2,951.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,819.94
|
| Rate for Payer: Aetna Managed Medicare |
$918.12
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,131.35
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,639.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,573.92
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,737.87
|
| Rate for Payer: Cash Price |
$983.70
|
| Rate for Payer: Cigna Commercial |
$3,016.68
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,834.93
|
| Rate for Payer: Health EOS Commercial |
$2,918.31
|
| Rate for Payer: HFN Commercial |
$3,016.68
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,459.25
|
| Rate for Payer: Multiplan Commercial |
$2,623.20
|
| Rate for Payer: NAPHCARE Commercial |
$1,967.40
|
| Rate for Payer: Preferred Network Access Commercial |
$3,016.68
|
| Rate for Payer: Quartz Beloit One Network |
$1,606.71
|
| Rate for Payer: Quartz Commercial |
$2,131.35
|
| Rate for Payer: Quartz Medicare Advantage |
$1,967.40
|
| Rate for Payer: The Alliance Commercial |
$13,116.00
|
| Rate for Payer: WEA Trust Commercial |
$1,803.45
|
| Rate for Payer: WPS Commercial |
$2,428.76
|
|
|
BALLOON CATHETER NEPHROMAX HIGH PRESSURE 30FR X 17CM M0062101620
|
Facility
|
IP
|
$3,279.00
|
|
|
Service Code
|
HCPCS C1726
|
| Hospital Charge Code |
5415203
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,606.71 |
| Max. Negotiated Rate |
$3,016.68 |
| Rate for Payer: Aetna Commercial |
$2,951.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,819.94
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,737.87
|
| Rate for Payer: Cash Price |
$983.70
|
| Rate for Payer: Cigna Commercial |
$3,016.68
|
| Rate for Payer: Health EOS Commercial |
$2,918.31
|
| Rate for Payer: HFN Commercial |
$3,016.68
|
| Rate for Payer: Multiplan Commercial |
$2,623.20
|
| Rate for Payer: NAPHCARE Commercial |
$1,967.40
|
| Rate for Payer: Preferred Network Access Commercial |
$3,016.68
|
| Rate for Payer: Quartz Beloit One Network |
$1,606.71
|
| Rate for Payer: Quartz Commercial |
$1,967.40
|
| Rate for Payer: WEA Trust Commercial |
$1,803.45
|
| Rate for Payer: WPS Commercial |
$2,428.76
|
|
|
BALLOON CATHETER NEPHROMAX HIGH PRESSURE 30FR X 20CM PTFE M0062101440
|
Facility
|
IP
|
$2,909.00
|
|
|
Service Code
|
HCPCS C1726
|
| Hospital Charge Code |
5496948
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,425.41 |
| Max. Negotiated Rate |
$2,676.28 |
| Rate for Payer: Aetna Commercial |
$2,618.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,501.74
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,541.77
|
| Rate for Payer: Cash Price |
$872.70
|
| Rate for Payer: Cigna Commercial |
$2,676.28
|
| Rate for Payer: Health EOS Commercial |
$2,589.01
|
| Rate for Payer: HFN Commercial |
$2,676.28
|
| Rate for Payer: Multiplan Commercial |
$2,327.20
|
| Rate for Payer: NAPHCARE Commercial |
$1,745.40
|
| Rate for Payer: Preferred Network Access Commercial |
$2,676.28
|
| Rate for Payer: Quartz Beloit One Network |
$1,425.41
|
| Rate for Payer: Quartz Commercial |
$1,745.40
|
| Rate for Payer: WEA Trust Commercial |
$1,599.95
|
| Rate for Payer: WPS Commercial |
$2,154.70
|
|
|
BALLOON CATHETER NEPHROMAX HIGH PRESSURE 30FR X 20CM PTFE M0062101440
|
Facility
|
OP
|
$2,909.00
|
|
|
Service Code
|
HCPCS C1726
|
| Hospital Charge Code |
5496948
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$814.52 |
| Max. Negotiated Rate |
$11,636.00 |
| Rate for Payer: Aetna Commercial |
$2,618.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,501.74
|
| Rate for Payer: Aetna Managed Medicare |
$814.52
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,890.85
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,454.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,396.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,541.77
|
| Rate for Payer: Cash Price |
$872.70
|
| Rate for Payer: Cigna Commercial |
$2,676.28
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,627.88
|
| Rate for Payer: Health EOS Commercial |
$2,589.01
|
| Rate for Payer: HFN Commercial |
$2,676.28
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,181.75
|
| Rate for Payer: Multiplan Commercial |
$2,327.20
|
| Rate for Payer: NAPHCARE Commercial |
$1,745.40
|
| Rate for Payer: Preferred Network Access Commercial |
$2,676.28
|
| Rate for Payer: Quartz Beloit One Network |
$1,425.41
|
| Rate for Payer: Quartz Commercial |
$1,890.85
|
| Rate for Payer: Quartz Medicare Advantage |
$1,745.40
|
| Rate for Payer: The Alliance Commercial |
$11,636.00
|
| Rate for Payer: WEA Trust Commercial |
$1,599.95
|
| Rate for Payer: WPS Commercial |
$2,154.70
|
|
|
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: Aetna Gatekeeper/Not Gatekeeper |
$730.14
|
| 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 10MM X 2CM X 75CM X 5.8F X .035 CQ75102
|
Facility
|
OP
|
$2,005.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
6204998
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$561.40 |
| Max. Negotiated Rate |
$8,020.00 |
| 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: The Alliance Commercial |
$8,020.00
|
| Rate for Payer: WEA Trust Commercial |
$1,102.75
|
| Rate for Payer: WPS Commercial |
$1,485.10
|
|
|
BALLOON CONQUEST 10MM X 2CM X 75CM X 5.8F X .035 CQ75102
|
Facility
|
IP
|
$2,005.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
6204998
|
|
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: Aetna Gatekeeper/Not Gatekeeper |
$1,724.30
|
| 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 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: Aetna Gatekeeper/Not Gatekeeper |
$1,724.30
|
| 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 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 |
$8,020.00 |
| 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: The Alliance Commercial |
$8,020.00
|
| 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 |
$8,020.00 |
| 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: The Alliance Commercial |
$8,020.00
|
| 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: Aetna Gatekeeper/Not Gatekeeper |
$1,724.30
|
| 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 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: Aetna Gatekeeper/Not Gatekeeper |
$1,724.30
|
| 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 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 |
$8,020.00 |
| 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: The Alliance Commercial |
$8,020.00
|
| 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 |
$8,020.00 |
| 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: The Alliance Commercial |
$8,020.00
|
| 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: Aetna Gatekeeper/Not Gatekeeper |
$1,724.30
|
| 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
|
|
