|
BALLOON 4.0x80mm AB35W04080135
|
Facility
|
IP
|
$1,708.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
2972485
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$870.40 |
| Max. Negotiated Rate |
$1,634.21 |
| Rate for Payer: Aetna Commercial |
$1,598.69
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,527.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$941.45
|
| Rate for Payer: Cash Price |
$512.40
|
| Rate for Payer: Cigna Commercial |
$1,634.21
|
| Rate for Payer: Health EOS Commercial |
$1,580.92
|
| Rate for Payer: HFN Commercial |
$1,634.21
|
| Rate for Payer: Multiplan Commercial |
$1,421.06
|
| Rate for Payer: Preferred Network Access Commercial |
$1,634.21
|
| Rate for Payer: Quartz Beloit One Network |
$870.40
|
| Rate for Payer: Quartz Commercial |
$1,065.79
|
| Rate for Payer: WEA Trust Commercial |
$976.98
|
| Rate for Payer: WPS Commercial |
$1,315.67
|
|
|
BALLOON 4mmX20mm AB35W04020080
|
Facility
|
OP
|
$1,708.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
2972511
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$497.37 |
| Max. Negotiated Rate |
$1,634.21 |
| Rate for Payer: Aetna Commercial |
$1,598.69
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,527.64
|
| Rate for Payer: Aetna Managed Medicare |
$497.37
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,154.61
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$888.16
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$852.63
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$941.45
|
| Rate for Payer: Cash Price |
$512.40
|
| Rate for Payer: Cigna Commercial |
$1,634.21
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$994.06
|
| Rate for Payer: Health EOS Commercial |
$1,580.92
|
| Rate for Payer: HFN Commercial |
$1,634.21
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,332.24
|
| Rate for Payer: Multiplan Commercial |
$1,421.06
|
| Rate for Payer: NAPHCARE Commercial |
$1,065.79
|
| Rate for Payer: Preferred Network Access Commercial |
$1,634.21
|
| Rate for Payer: Quartz Beloit One Network |
$870.40
|
| Rate for Payer: Quartz Commercial |
$1,154.61
|
| Rate for Payer: Quartz Medicare Advantage |
$1,065.79
|
| Rate for Payer: The Alliance Commercial |
$888.16
|
| Rate for Payer: WEA Trust Commercial |
$976.98
|
| Rate for Payer: WPS Commercial |
$1,315.67
|
|
|
BALLOON 4mmX20mm AB35W04020080
|
Facility
|
IP
|
$1,708.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
2972511
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$870.40 |
| Max. Negotiated Rate |
$1,634.21 |
| Rate for Payer: Aetna Commercial |
$1,598.69
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,527.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$941.45
|
| Rate for Payer: Cash Price |
$512.40
|
| Rate for Payer: Cigna Commercial |
$1,634.21
|
| Rate for Payer: Health EOS Commercial |
$1,580.92
|
| Rate for Payer: HFN Commercial |
$1,634.21
|
| Rate for Payer: Multiplan Commercial |
$1,421.06
|
| Rate for Payer: Preferred Network Access Commercial |
$1,634.21
|
| Rate for Payer: Quartz Beloit One Network |
$870.40
|
| Rate for Payer: Quartz Commercial |
$1,065.79
|
| Rate for Payer: WEA Trust Commercial |
$976.98
|
| Rate for Payer: WPS Commercial |
$1,315.67
|
|
|
BALLOON 4mmX4cm AB35W04040080
|
Facility
|
IP
|
$1,708.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
2972937
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$870.40 |
| Max. Negotiated Rate |
$1,634.21 |
| Rate for Payer: Aetna Commercial |
$1,598.69
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,527.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$941.45
|
| Rate for Payer: Cash Price |
$512.40
|
| Rate for Payer: Cigna Commercial |
$1,634.21
|
| Rate for Payer: Health EOS Commercial |
$1,580.92
|
| Rate for Payer: HFN Commercial |
$1,634.21
|
| Rate for Payer: Multiplan Commercial |
$1,421.06
|
| Rate for Payer: Preferred Network Access Commercial |
$1,634.21
|
| Rate for Payer: Quartz Beloit One Network |
$870.40
|
| Rate for Payer: Quartz Commercial |
$1,065.79
|
| Rate for Payer: WEA Trust Commercial |
$976.98
|
| Rate for Payer: WPS Commercial |
$1,315.67
|
|
|
BALLOON 4mmX4cm AB35W04040080
|
Facility
|
OP
|
$1,708.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
2972937
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$497.37 |
| Max. Negotiated Rate |
$1,634.21 |
| Rate for Payer: Aetna Commercial |
$1,598.69
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,527.64
|
| Rate for Payer: Aetna Managed Medicare |
$497.37
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,154.61
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$888.16
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$852.63
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$941.45
|
| Rate for Payer: Cash Price |
$512.40
|
| Rate for Payer: Cigna Commercial |
$1,634.21
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$994.06
|
| Rate for Payer: Health EOS Commercial |
$1,580.92
|
| Rate for Payer: HFN Commercial |
$1,634.21
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,332.24
|
| Rate for Payer: Multiplan Commercial |
$1,421.06
|
| Rate for Payer: NAPHCARE Commercial |
$1,065.79
|
| Rate for Payer: Preferred Network Access Commercial |
$1,634.21
|
| Rate for Payer: Quartz Beloit One Network |
$870.40
|
| Rate for Payer: Quartz Commercial |
$1,154.61
|
| Rate for Payer: Quartz Medicare Advantage |
$1,065.79
|
| Rate for Payer: The Alliance Commercial |
$888.16
|
| Rate for Payer: WEA Trust Commercial |
$976.98
|
| Rate for Payer: WPS Commercial |
$1,315.67
|
|
|
BALLOON 4mmX6cm AB35W04060080
|
Facility
|
IP
|
$1,708.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
2972517
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$870.40 |
| Max. Negotiated Rate |
$1,634.21 |
| Rate for Payer: Aetna Commercial |
$1,598.69
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,527.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$941.45
|
| Rate for Payer: Cash Price |
$512.40
|
| Rate for Payer: Cigna Commercial |
$1,634.21
|
| Rate for Payer: Health EOS Commercial |
$1,580.92
|
| Rate for Payer: HFN Commercial |
$1,634.21
|
| Rate for Payer: Multiplan Commercial |
$1,421.06
|
| Rate for Payer: Preferred Network Access Commercial |
$1,634.21
|
| Rate for Payer: Quartz Beloit One Network |
$870.40
|
| Rate for Payer: Quartz Commercial |
$1,065.79
|
| Rate for Payer: WEA Trust Commercial |
$976.98
|
| Rate for Payer: WPS Commercial |
$1,315.67
|
|
|
BALLOON 4mmX6cm AB35W04060080
|
Facility
|
OP
|
$1,708.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
2972517
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$497.37 |
| Max. Negotiated Rate |
$1,634.21 |
| Rate for Payer: Aetna Commercial |
$1,598.69
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,527.64
|
| Rate for Payer: Aetna Managed Medicare |
$497.37
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,154.61
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$888.16
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$852.63
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$941.45
|
| Rate for Payer: Cash Price |
$512.40
|
| Rate for Payer: Cigna Commercial |
$1,634.21
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$994.06
|
| Rate for Payer: Health EOS Commercial |
$1,580.92
|
| Rate for Payer: HFN Commercial |
$1,634.21
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,332.24
|
| Rate for Payer: Multiplan Commercial |
$1,421.06
|
| Rate for Payer: NAPHCARE Commercial |
$1,065.79
|
| Rate for Payer: Preferred Network Access Commercial |
$1,634.21
|
| Rate for Payer: Quartz Beloit One Network |
$870.40
|
| Rate for Payer: Quartz Commercial |
$1,154.61
|
| Rate for Payer: Quartz Medicare Advantage |
$1,065.79
|
| Rate for Payer: The Alliance Commercial |
$888.16
|
| Rate for Payer: WEA Trust Commercial |
$976.98
|
| Rate for Payer: WPS Commercial |
$1,315.67
|
|
|
BALLOON 4X 100mm AB35W04100135
|
Facility
|
IP
|
$1,708.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
2972496
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$870.40 |
| Max. Negotiated Rate |
$1,634.21 |
| Rate for Payer: Aetna Commercial |
$1,598.69
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,527.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$941.45
|
| Rate for Payer: Cash Price |
$512.40
|
| Rate for Payer: Cigna Commercial |
$1,634.21
|
| Rate for Payer: Health EOS Commercial |
$1,580.92
|
| Rate for Payer: HFN Commercial |
$1,634.21
|
| Rate for Payer: Multiplan Commercial |
$1,421.06
|
| Rate for Payer: Preferred Network Access Commercial |
$1,634.21
|
| Rate for Payer: Quartz Beloit One Network |
$870.40
|
| Rate for Payer: Quartz Commercial |
$1,065.79
|
| Rate for Payer: WEA Trust Commercial |
$976.98
|
| Rate for Payer: WPS Commercial |
$1,315.67
|
|
|
BALLOON 4X 100mm AB35W04100135
|
Facility
|
OP
|
$1,708.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
2972496
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$497.37 |
| Max. Negotiated Rate |
$1,634.21 |
| Rate for Payer: Aetna Commercial |
$1,598.69
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,527.64
|
| Rate for Payer: Aetna Managed Medicare |
$497.37
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,154.61
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$888.16
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$852.63
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$941.45
|
| Rate for Payer: Cash Price |
$512.40
|
| Rate for Payer: Cigna Commercial |
$1,634.21
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$994.06
|
| Rate for Payer: Health EOS Commercial |
$1,580.92
|
| Rate for Payer: HFN Commercial |
$1,634.21
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,332.24
|
| Rate for Payer: Multiplan Commercial |
$1,421.06
|
| Rate for Payer: NAPHCARE Commercial |
$1,065.79
|
| Rate for Payer: Preferred Network Access Commercial |
$1,634.21
|
| Rate for Payer: Quartz Beloit One Network |
$870.40
|
| Rate for Payer: Quartz Commercial |
$1,154.61
|
| Rate for Payer: Quartz Medicare Advantage |
$1,065.79
|
| Rate for Payer: The Alliance Commercial |
$888.16
|
| Rate for Payer: WEA Trust Commercial |
$976.98
|
| Rate for Payer: WPS Commercial |
$1,315.67
|
|
|
BALLOON 4x10 HURRICANE DILATOR 4596
|
Facility
|
IP
|
$2,794.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
2973262
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,423.82 |
| Max. Negotiated Rate |
$2,673.30 |
| Rate for Payer: Aetna Commercial |
$2,615.18
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,498.95
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,540.05
|
| Rate for Payer: Cash Price |
$838.20
|
| Rate for Payer: Cigna Commercial |
$2,673.30
|
| Rate for Payer: Health EOS Commercial |
$2,586.13
|
| Rate for Payer: HFN Commercial |
$2,673.30
|
| Rate for Payer: Multiplan Commercial |
$2,324.61
|
| Rate for Payer: Preferred Network Access Commercial |
$2,673.30
|
| Rate for Payer: Quartz Beloit One Network |
$1,423.82
|
| Rate for Payer: Quartz Commercial |
$1,743.46
|
| Rate for Payer: WEA Trust Commercial |
$1,598.17
|
| Rate for Payer: WPS Commercial |
$2,152.22
|
|
|
BALLOON 4x10 HURRICANE DILATOR 4596
|
Facility
|
OP
|
$2,794.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
2973262
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$813.61 |
| Max. Negotiated Rate |
$2,673.30 |
| Rate for Payer: Aetna Commercial |
$2,615.18
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,498.95
|
| Rate for Payer: Aetna Managed Medicare |
$813.61
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,888.74
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,452.88
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,394.76
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,540.05
|
| Rate for Payer: Cash Price |
$838.20
|
| Rate for Payer: Cigna Commercial |
$2,673.30
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,626.11
|
| Rate for Payer: Health EOS Commercial |
$2,586.13
|
| Rate for Payer: HFN Commercial |
$2,673.30
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,179.32
|
| Rate for Payer: Multiplan Commercial |
$2,324.61
|
| Rate for Payer: NAPHCARE Commercial |
$1,743.46
|
| Rate for Payer: Preferred Network Access Commercial |
$2,673.30
|
| Rate for Payer: Quartz Beloit One Network |
$1,423.82
|
| Rate for Payer: Quartz Commercial |
$1,888.74
|
| Rate for Payer: Quartz Medicare Advantage |
$1,743.46
|
| Rate for Payer: The Alliance Commercial |
$1,452.88
|
| Rate for Payer: WEA Trust Commercial |
$1,598.17
|
| Rate for Payer: WPS Commercial |
$2,152.22
|
|
|
BALLOON 4 X 120 AB35W04120135
|
Facility
|
OP
|
$1,708.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
2972489
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$497.37 |
| Max. Negotiated Rate |
$1,634.21 |
| Rate for Payer: Aetna Commercial |
$1,598.69
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,527.64
|
| Rate for Payer: Aetna Managed Medicare |
$497.37
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,154.61
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$888.16
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$852.63
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$941.45
|
| Rate for Payer: Cash Price |
$512.40
|
| Rate for Payer: Cigna Commercial |
$1,634.21
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$994.06
|
| Rate for Payer: Health EOS Commercial |
$1,580.92
|
| Rate for Payer: HFN Commercial |
$1,634.21
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,332.24
|
| Rate for Payer: Multiplan Commercial |
$1,421.06
|
| Rate for Payer: NAPHCARE Commercial |
$1,065.79
|
| Rate for Payer: Preferred Network Access Commercial |
$1,634.21
|
| Rate for Payer: Quartz Beloit One Network |
$870.40
|
| Rate for Payer: Quartz Commercial |
$1,154.61
|
| Rate for Payer: Quartz Medicare Advantage |
$1,065.79
|
| Rate for Payer: The Alliance Commercial |
$888.16
|
| Rate for Payer: WEA Trust Commercial |
$976.98
|
| Rate for Payer: WPS Commercial |
$1,315.67
|
|
|
BALLOON 4 X 120 AB35W04120135
|
Facility
|
IP
|
$1,708.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
2972489
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$870.40 |
| Max. Negotiated Rate |
$1,634.21 |
| Rate for Payer: Aetna Commercial |
$1,598.69
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,527.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$941.45
|
| Rate for Payer: Cash Price |
$512.40
|
| Rate for Payer: Cigna Commercial |
$1,634.21
|
| Rate for Payer: Health EOS Commercial |
$1,580.92
|
| Rate for Payer: HFN Commercial |
$1,634.21
|
| Rate for Payer: Multiplan Commercial |
$1,421.06
|
| Rate for Payer: Preferred Network Access Commercial |
$1,634.21
|
| Rate for Payer: Quartz Beloit One Network |
$870.40
|
| Rate for Payer: Quartz Commercial |
$1,065.79
|
| Rate for Payer: WEA Trust Commercial |
$976.98
|
| Rate for Payer: WPS Commercial |
$1,315.67
|
|
|
BALLOON 4X 150mm AB35W04150135
|
Facility
|
IP
|
$1,753.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
2972687
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$893.33 |
| Max. Negotiated Rate |
$1,677.27 |
| Rate for Payer: Aetna Commercial |
$1,640.81
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,567.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$966.25
|
| Rate for Payer: Cash Price |
$525.90
|
| Rate for Payer: Cigna Commercial |
$1,677.27
|
| Rate for Payer: Health EOS Commercial |
$1,622.58
|
| Rate for Payer: HFN Commercial |
$1,677.27
|
| Rate for Payer: Multiplan Commercial |
$1,458.50
|
| Rate for Payer: Preferred Network Access Commercial |
$1,677.27
|
| Rate for Payer: Quartz Beloit One Network |
$893.33
|
| Rate for Payer: Quartz Commercial |
$1,093.87
|
| Rate for Payer: WEA Trust Commercial |
$1,002.72
|
| Rate for Payer: WPS Commercial |
$1,350.34
|
|
|
BALLOON 4X 150mm AB35W04150135
|
Facility
|
OP
|
$1,753.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
2972687
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$510.47 |
| Max. Negotiated Rate |
$1,677.27 |
| Rate for Payer: Aetna Commercial |
$1,640.81
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,567.88
|
| Rate for Payer: Aetna Managed Medicare |
$510.47
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,185.03
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$911.56
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$875.10
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$966.25
|
| Rate for Payer: Cash Price |
$525.90
|
| Rate for Payer: Cigna Commercial |
$1,677.27
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,020.25
|
| Rate for Payer: Health EOS Commercial |
$1,622.58
|
| Rate for Payer: HFN Commercial |
$1,677.27
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,367.34
|
| Rate for Payer: Multiplan Commercial |
$1,458.50
|
| Rate for Payer: NAPHCARE Commercial |
$1,093.87
|
| Rate for Payer: Preferred Network Access Commercial |
$1,677.27
|
| Rate for Payer: Quartz Beloit One Network |
$893.33
|
| Rate for Payer: Quartz Commercial |
$1,185.03
|
| Rate for Payer: Quartz Medicare Advantage |
$1,093.87
|
| Rate for Payer: The Alliance Commercial |
$911.56
|
| Rate for Payer: WEA Trust Commercial |
$1,002.72
|
| Rate for Payer: WPS Commercial |
$1,350.34
|
|
|
BALLOON 4.X 40mm AB35W04040135
|
Facility
|
IP
|
$2,288.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
2972939
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,165.96 |
| Max. Negotiated Rate |
$2,189.16 |
| Rate for Payer: Aetna Commercial |
$2,141.57
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,046.39
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,261.15
|
| Rate for Payer: Cash Price |
$686.40
|
| Rate for Payer: Cigna Commercial |
$2,189.16
|
| Rate for Payer: Health EOS Commercial |
$2,117.77
|
| Rate for Payer: HFN Commercial |
$2,189.16
|
| Rate for Payer: Multiplan Commercial |
$1,903.62
|
| Rate for Payer: Preferred Network Access Commercial |
$2,189.16
|
| Rate for Payer: Quartz Beloit One Network |
$1,165.96
|
| Rate for Payer: Quartz Commercial |
$1,427.71
|
| Rate for Payer: WEA Trust Commercial |
$1,308.74
|
| Rate for Payer: WPS Commercial |
$1,762.45
|
|
|
BALLOON 4.X 40mm AB35W04040135
|
Facility
|
OP
|
$2,288.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
2972939
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$666.27 |
| Max. Negotiated Rate |
$2,189.16 |
| Rate for Payer: Aetna Commercial |
$2,141.57
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,046.39
|
| Rate for Payer: Aetna Managed Medicare |
$666.27
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,546.69
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,189.76
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,142.17
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,261.15
|
| Rate for Payer: Cash Price |
$686.40
|
| Rate for Payer: Cigna Commercial |
$2,189.16
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,331.62
|
| Rate for Payer: Health EOS Commercial |
$2,117.77
|
| Rate for Payer: HFN Commercial |
$2,189.16
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,784.64
|
| Rate for Payer: Multiplan Commercial |
$1,903.62
|
| Rate for Payer: NAPHCARE Commercial |
$1,427.71
|
| Rate for Payer: Preferred Network Access Commercial |
$2,189.16
|
| Rate for Payer: Quartz Beloit One Network |
$1,165.96
|
| Rate for Payer: Quartz Commercial |
$1,546.69
|
| Rate for Payer: Quartz Medicare Advantage |
$1,427.71
|
| Rate for Payer: The Alliance Commercial |
$1,189.76
|
| Rate for Payer: WEA Trust Commercial |
$1,308.74
|
| Rate for Payer: WPS Commercial |
$1,762.45
|
|
|
BALLOON 4x4 HURRICANE DILATOR 4590
|
Facility
|
OP
|
$2,794.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
2973260
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$813.61 |
| Max. Negotiated Rate |
$2,673.30 |
| Rate for Payer: Aetna Commercial |
$2,615.18
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,498.95
|
| Rate for Payer: Aetna Managed Medicare |
$813.61
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,888.74
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,452.88
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,394.76
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,540.05
|
| Rate for Payer: Cash Price |
$838.20
|
| Rate for Payer: Cigna Commercial |
$2,673.30
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,626.11
|
| Rate for Payer: Health EOS Commercial |
$2,586.13
|
| Rate for Payer: HFN Commercial |
$2,673.30
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,179.32
|
| Rate for Payer: Multiplan Commercial |
$2,324.61
|
| Rate for Payer: NAPHCARE Commercial |
$1,743.46
|
| Rate for Payer: Preferred Network Access Commercial |
$2,673.30
|
| Rate for Payer: Quartz Beloit One Network |
$1,423.82
|
| Rate for Payer: Quartz Commercial |
$1,888.74
|
| Rate for Payer: Quartz Medicare Advantage |
$1,743.46
|
| Rate for Payer: The Alliance Commercial |
$1,452.88
|
| Rate for Payer: WEA Trust Commercial |
$1,598.17
|
| Rate for Payer: WPS Commercial |
$2,152.22
|
|
|
BALLOON 4x4 HURRICANE DILATOR 4590
|
Facility
|
IP
|
$2,794.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
2973260
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,423.82 |
| Max. Negotiated Rate |
$2,673.30 |
| Rate for Payer: Aetna Commercial |
$2,615.18
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,498.95
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,540.05
|
| Rate for Payer: Cash Price |
$838.20
|
| Rate for Payer: Cigna Commercial |
$2,673.30
|
| Rate for Payer: Health EOS Commercial |
$2,586.13
|
| Rate for Payer: HFN Commercial |
$2,673.30
|
| Rate for Payer: Multiplan Commercial |
$2,324.61
|
| Rate for Payer: Preferred Network Access Commercial |
$2,673.30
|
| Rate for Payer: Quartz Beloit One Network |
$1,423.82
|
| Rate for Payer: Quartz Commercial |
$1,743.46
|
| Rate for Payer: WEA Trust Commercial |
$1,598.17
|
| Rate for Payer: WPS Commercial |
$2,152.22
|
|
|
BALLOON 4 x 60mm AB35W04060135
|
Facility
|
OP
|
$1,708.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
2972490
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$497.37 |
| Max. Negotiated Rate |
$1,634.21 |
| Rate for Payer: Aetna Commercial |
$1,598.69
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,527.64
|
| Rate for Payer: Aetna Managed Medicare |
$497.37
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,154.61
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$888.16
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$852.63
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$941.45
|
| Rate for Payer: Cash Price |
$512.40
|
| Rate for Payer: Cigna Commercial |
$1,634.21
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$994.06
|
| Rate for Payer: Health EOS Commercial |
$1,580.92
|
| Rate for Payer: HFN Commercial |
$1,634.21
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,332.24
|
| Rate for Payer: Multiplan Commercial |
$1,421.06
|
| Rate for Payer: NAPHCARE Commercial |
$1,065.79
|
| Rate for Payer: Preferred Network Access Commercial |
$1,634.21
|
| Rate for Payer: Quartz Beloit One Network |
$870.40
|
| Rate for Payer: Quartz Commercial |
$1,154.61
|
| Rate for Payer: Quartz Medicare Advantage |
$1,065.79
|
| Rate for Payer: The Alliance Commercial |
$888.16
|
| Rate for Payer: WEA Trust Commercial |
$976.98
|
| Rate for Payer: WPS Commercial |
$1,315.67
|
|
|
BALLOON 4 x 60mm AB35W04060135
|
Facility
|
IP
|
$1,708.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
2972490
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$870.40 |
| Max. Negotiated Rate |
$1,634.21 |
| Rate for Payer: Aetna Commercial |
$1,598.69
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,527.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$941.45
|
| Rate for Payer: Cash Price |
$512.40
|
| Rate for Payer: Cigna Commercial |
$1,634.21
|
| Rate for Payer: Health EOS Commercial |
$1,580.92
|
| Rate for Payer: HFN Commercial |
$1,634.21
|
| Rate for Payer: Multiplan Commercial |
$1,421.06
|
| Rate for Payer: Preferred Network Access Commercial |
$1,634.21
|
| Rate for Payer: Quartz Beloit One Network |
$870.40
|
| Rate for Payer: Quartz Commercial |
$1,065.79
|
| Rate for Payer: WEA Trust Commercial |
$976.98
|
| Rate for Payer: WPS Commercial |
$1,315.67
|
|
|
BALLOON 4x6 HURRICANE DILATOR 4592
|
Facility
|
IP
|
$2,902.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
2973261
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,478.86 |
| Max. Negotiated Rate |
$2,776.63 |
| Rate for Payer: Aetna Commercial |
$2,716.27
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,595.55
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,599.58
|
| Rate for Payer: Cash Price |
$870.60
|
| Rate for Payer: Cigna Commercial |
$2,776.63
|
| Rate for Payer: Health EOS Commercial |
$2,686.09
|
| Rate for Payer: HFN Commercial |
$2,776.63
|
| Rate for Payer: Multiplan Commercial |
$2,414.46
|
| Rate for Payer: Preferred Network Access Commercial |
$2,776.63
|
| Rate for Payer: Quartz Beloit One Network |
$1,478.86
|
| Rate for Payer: Quartz Commercial |
$1,810.85
|
| Rate for Payer: WEA Trust Commercial |
$1,659.94
|
| Rate for Payer: WPS Commercial |
$2,235.41
|
|
|
BALLOON 4x6 HURRICANE DILATOR 4592
|
Facility
|
OP
|
$2,902.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
2973261
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$845.06 |
| Max. Negotiated Rate |
$2,776.63 |
| Rate for Payer: Aetna Commercial |
$2,716.27
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,595.55
|
| Rate for Payer: Aetna Managed Medicare |
$845.06
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,961.75
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,509.04
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,448.68
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,599.58
|
| Rate for Payer: Cash Price |
$870.60
|
| Rate for Payer: Cigna Commercial |
$2,776.63
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,688.96
|
| Rate for Payer: Health EOS Commercial |
$2,686.09
|
| Rate for Payer: HFN Commercial |
$2,776.63
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,263.56
|
| Rate for Payer: Multiplan Commercial |
$2,414.46
|
| Rate for Payer: NAPHCARE Commercial |
$1,810.85
|
| Rate for Payer: Preferred Network Access Commercial |
$2,776.63
|
| Rate for Payer: Quartz Beloit One Network |
$1,478.86
|
| Rate for Payer: Quartz Commercial |
$1,961.75
|
| Rate for Payer: Quartz Medicare Advantage |
$1,810.85
|
| Rate for Payer: The Alliance Commercial |
$1,509.04
|
| Rate for Payer: WEA Trust Commercial |
$1,659.94
|
| Rate for Payer: WPS Commercial |
$2,235.41
|
|
|
BALLOON 5.0 X 60 AB35W05060080
|
Facility
|
OP
|
$1,708.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
2972936
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$497.37 |
| Max. Negotiated Rate |
$1,634.21 |
| Rate for Payer: Aetna Commercial |
$1,598.69
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,527.64
|
| Rate for Payer: Aetna Managed Medicare |
$497.37
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,154.61
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$888.16
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$852.63
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$941.45
|
| Rate for Payer: Cash Price |
$512.40
|
| Rate for Payer: Cigna Commercial |
$1,634.21
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$994.06
|
| Rate for Payer: Health EOS Commercial |
$1,580.92
|
| Rate for Payer: HFN Commercial |
$1,634.21
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,332.24
|
| Rate for Payer: Multiplan Commercial |
$1,421.06
|
| Rate for Payer: NAPHCARE Commercial |
$1,065.79
|
| Rate for Payer: Preferred Network Access Commercial |
$1,634.21
|
| Rate for Payer: Quartz Beloit One Network |
$870.40
|
| Rate for Payer: Quartz Commercial |
$1,154.61
|
| Rate for Payer: Quartz Medicare Advantage |
$1,065.79
|
| Rate for Payer: The Alliance Commercial |
$888.16
|
| Rate for Payer: WEA Trust Commercial |
$976.98
|
| Rate for Payer: WPS Commercial |
$1,315.67
|
|
|
BALLOON 5.0 X 60 AB35W05060080
|
Facility
|
IP
|
$1,708.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
2972936
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$870.40 |
| Max. Negotiated Rate |
$1,634.21 |
| Rate for Payer: Aetna Commercial |
$1,598.69
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,527.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$941.45
|
| Rate for Payer: Cash Price |
$512.40
|
| Rate for Payer: Cigna Commercial |
$1,634.21
|
| Rate for Payer: Health EOS Commercial |
$1,580.92
|
| Rate for Payer: HFN Commercial |
$1,634.21
|
| Rate for Payer: Multiplan Commercial |
$1,421.06
|
| Rate for Payer: Preferred Network Access Commercial |
$1,634.21
|
| Rate for Payer: Quartz Beloit One Network |
$870.40
|
| Rate for Payer: Quartz Commercial |
$1,065.79
|
| Rate for Payer: WEA Trust Commercial |
$976.98
|
| Rate for Payer: WPS Commercial |
$1,315.67
|
|
