|
BALLOON 8 X 40mm AB35W08040080
|
Facility
|
IP
|
$1,708.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
2972505
|
|
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 9.0 X20 AB35W09020080
|
Facility
|
IP
|
$1,708.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
2972516
|
|
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 9.0 X20 AB35W09020080
|
Facility
|
OP
|
$1,708.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
2972516
|
|
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 9.0 X40 AB35W09040080
|
Facility
|
OP
|
$1,708.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
2972513
|
|
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 9.0 X40 AB35W09040080
|
Facility
|
IP
|
$1,708.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
2972513
|
|
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 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 |
$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 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 |
$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 9 X 60mm AB35W09060080
|
Facility
|
OP
|
$1,708.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
2972491
|
|
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 9 X 60mm AB35W09060080
|
Facility
|
IP
|
$1,708.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
2972491
|
|
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 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 |
$1,388.15 |
| Max. Negotiated Rate |
$2,606.32 |
| Rate for Payer: Aetna Commercial |
$2,549.66
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,436.35
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,501.47
|
| Rate for Payer: Cash Price |
$817.20
|
| Rate for Payer: Cigna Commercial |
$2,606.32
|
| Rate for Payer: Health EOS Commercial |
$2,521.33
|
| Rate for Payer: HFN Commercial |
$2,606.32
|
| Rate for Payer: Multiplan Commercial |
$2,266.37
|
| Rate for Payer: Preferred Network Access Commercial |
$2,606.32
|
| Rate for Payer: Quartz Beloit One Network |
$1,388.15
|
| Rate for Payer: Quartz Commercial |
$1,699.78
|
| Rate for Payer: WEA Trust Commercial |
$1,558.13
|
| Rate for Payer: WPS Commercial |
$2,098.30
|
|
|
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 |
$793.23 |
| Max. Negotiated Rate |
$2,606.32 |
| Rate for Payer: Aetna Commercial |
$2,549.66
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,436.35
|
| Rate for Payer: Aetna Managed Medicare |
$793.23
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,841.42
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,416.48
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,359.82
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,501.47
|
| Rate for Payer: Cash Price |
$817.20
|
| Rate for Payer: Cigna Commercial |
$2,606.32
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,585.37
|
| Rate for Payer: Health EOS Commercial |
$2,521.33
|
| Rate for Payer: HFN Commercial |
$2,606.32
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,124.72
|
| Rate for Payer: Multiplan Commercial |
$2,266.37
|
| Rate for Payer: NAPHCARE Commercial |
$1,699.78
|
| Rate for Payer: Preferred Network Access Commercial |
$2,606.32
|
| Rate for Payer: Quartz Beloit One Network |
$1,388.15
|
| Rate for Payer: Quartz Commercial |
$1,841.42
|
| Rate for Payer: Quartz Medicare Advantage |
$1,699.78
|
| Rate for Payer: The Alliance Commercial |
$1,416.48
|
| Rate for Payer: WEA Trust Commercial |
$1,558.13
|
| Rate for Payer: WPS Commercial |
$2,098.30
|
|
|
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 |
$798.76 |
| Max. Negotiated Rate |
$2,624.50 |
| Rate for Payer: Aetna Commercial |
$2,567.45
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,453.34
|
| Rate for Payer: Aetna Managed Medicare |
$798.76
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,854.27
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,426.36
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,369.31
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,511.94
|
| Rate for Payer: Cash Price |
$822.90
|
| Rate for Payer: Cigna Commercial |
$2,624.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,596.43
|
| Rate for Payer: Health EOS Commercial |
$2,538.92
|
| Rate for Payer: HFN Commercial |
$2,624.50
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,139.54
|
| Rate for Payer: Multiplan Commercial |
$2,282.18
|
| Rate for Payer: NAPHCARE Commercial |
$1,711.63
|
| Rate for Payer: Preferred Network Access Commercial |
$2,624.50
|
| Rate for Payer: Quartz Beloit One Network |
$1,397.83
|
| Rate for Payer: Quartz Commercial |
$1,854.27
|
| Rate for Payer: Quartz Medicare Advantage |
$1,711.63
|
| Rate for Payer: The Alliance Commercial |
$1,426.36
|
| Rate for Payer: WEA Trust Commercial |
$1,569.00
|
| Rate for Payer: WPS Commercial |
$2,112.93
|
|
|
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 |
$1,397.83 |
| Max. Negotiated Rate |
$2,624.50 |
| Rate for Payer: Aetna Commercial |
$2,567.45
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,453.34
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,511.94
|
| Rate for Payer: Cash Price |
$822.90
|
| Rate for Payer: Cigna Commercial |
$2,624.50
|
| Rate for Payer: Health EOS Commercial |
$2,538.92
|
| Rate for Payer: HFN Commercial |
$2,624.50
|
| Rate for Payer: Multiplan Commercial |
$2,282.18
|
| Rate for Payer: Preferred Network Access Commercial |
$2,624.50
|
| Rate for Payer: Quartz Beloit One Network |
$1,397.83
|
| Rate for Payer: Quartz Commercial |
$1,711.63
|
| Rate for Payer: WEA Trust Commercial |
$1,569.00
|
| Rate for Payer: WPS Commercial |
$2,112.93
|
|
|
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 |
$798.76 |
| Max. Negotiated Rate |
$2,624.50 |
| Rate for Payer: Aetna Commercial |
$2,567.45
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,453.34
|
| Rate for Payer: Aetna Managed Medicare |
$798.76
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,854.27
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,426.36
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,369.31
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,511.94
|
| Rate for Payer: Cash Price |
$822.90
|
| Rate for Payer: Cigna Commercial |
$2,624.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,596.43
|
| Rate for Payer: Health EOS Commercial |
$2,538.92
|
| Rate for Payer: HFN Commercial |
$2,624.50
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,139.54
|
| Rate for Payer: Multiplan Commercial |
$2,282.18
|
| Rate for Payer: NAPHCARE Commercial |
$1,711.63
|
| Rate for Payer: Preferred Network Access Commercial |
$2,624.50
|
| Rate for Payer: Quartz Beloit One Network |
$1,397.83
|
| Rate for Payer: Quartz Commercial |
$1,854.27
|
| Rate for Payer: Quartz Medicare Advantage |
$1,711.63
|
| Rate for Payer: The Alliance Commercial |
$1,426.36
|
| Rate for Payer: WEA Trust Commercial |
$1,569.00
|
| Rate for Payer: WPS Commercial |
$2,112.93
|
|
|
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 |
$1,397.83 |
| Max. Negotiated Rate |
$2,624.50 |
| Rate for Payer: Aetna Commercial |
$2,567.45
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,453.34
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,511.94
|
| Rate for Payer: Cash Price |
$822.90
|
| Rate for Payer: Cigna Commercial |
$2,624.50
|
| Rate for Payer: Health EOS Commercial |
$2,538.92
|
| Rate for Payer: HFN Commercial |
$2,624.50
|
| Rate for Payer: Multiplan Commercial |
$2,282.18
|
| Rate for Payer: Preferred Network Access Commercial |
$2,624.50
|
| Rate for Payer: Quartz Beloit One Network |
$1,397.83
|
| Rate for Payer: Quartz Commercial |
$1,711.63
|
| Rate for Payer: WEA Trust Commercial |
$1,569.00
|
| Rate for Payer: WPS Commercial |
$2,112.93
|
|
|
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 |
$1,397.83 |
| Max. Negotiated Rate |
$2,624.50 |
| Rate for Payer: Aetna Commercial |
$2,567.45
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,453.34
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,511.94
|
| Rate for Payer: Cash Price |
$822.90
|
| Rate for Payer: Cigna Commercial |
$2,624.50
|
| Rate for Payer: Health EOS Commercial |
$2,538.92
|
| Rate for Payer: HFN Commercial |
$2,624.50
|
| Rate for Payer: Multiplan Commercial |
$2,282.18
|
| Rate for Payer: Preferred Network Access Commercial |
$2,624.50
|
| Rate for Payer: Quartz Beloit One Network |
$1,397.83
|
| Rate for Payer: Quartz Commercial |
$1,711.63
|
| Rate for Payer: WEA Trust Commercial |
$1,569.00
|
| Rate for Payer: WPS Commercial |
$2,112.93
|
|
|
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 |
$798.76 |
| Max. Negotiated Rate |
$2,624.50 |
| Rate for Payer: Aetna Commercial |
$2,567.45
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,453.34
|
| Rate for Payer: Aetna Managed Medicare |
$798.76
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,854.27
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,426.36
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,369.31
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,511.94
|
| Rate for Payer: Cash Price |
$822.90
|
| Rate for Payer: Cigna Commercial |
$2,624.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,596.43
|
| Rate for Payer: Health EOS Commercial |
$2,538.92
|
| Rate for Payer: HFN Commercial |
$2,624.50
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,139.54
|
| Rate for Payer: Multiplan Commercial |
$2,282.18
|
| Rate for Payer: NAPHCARE Commercial |
$1,711.63
|
| Rate for Payer: Preferred Network Access Commercial |
$2,624.50
|
| Rate for Payer: Quartz Beloit One Network |
$1,397.83
|
| Rate for Payer: Quartz Commercial |
$1,854.27
|
| Rate for Payer: Quartz Medicare Advantage |
$1,711.63
|
| Rate for Payer: The Alliance Commercial |
$1,426.36
|
| Rate for Payer: WEA Trust Commercial |
$1,569.00
|
| Rate for Payer: WPS Commercial |
$2,112.93
|
|
|
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 |
$1,445.74 |
| Max. Negotiated Rate |
$2,714.44 |
| Rate for Payer: Aetna Commercial |
$2,655.43
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,537.41
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,563.75
|
| Rate for Payer: Cash Price |
$851.10
|
| Rate for Payer: Cigna Commercial |
$2,714.44
|
| Rate for Payer: Health EOS Commercial |
$2,625.93
|
| Rate for Payer: HFN Commercial |
$2,714.44
|
| Rate for Payer: Multiplan Commercial |
$2,360.38
|
| Rate for Payer: Preferred Network Access Commercial |
$2,714.44
|
| Rate for Payer: Quartz Beloit One Network |
$1,445.74
|
| Rate for Payer: Quartz Commercial |
$1,770.29
|
| Rate for Payer: WEA Trust Commercial |
$1,622.76
|
| Rate for Payer: WPS Commercial |
$2,185.34
|
|
|
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 |
$826.13 |
| Max. Negotiated Rate |
$2,714.44 |
| Rate for Payer: Aetna Commercial |
$2,655.43
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,537.41
|
| Rate for Payer: Aetna Managed Medicare |
$826.13
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,917.81
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,475.24
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,416.23
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,563.75
|
| Rate for Payer: Cash Price |
$851.10
|
| Rate for Payer: Cigna Commercial |
$2,714.44
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,651.13
|
| Rate for Payer: Health EOS Commercial |
$2,625.93
|
| Rate for Payer: HFN Commercial |
$2,714.44
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,212.86
|
| Rate for Payer: Multiplan Commercial |
$2,360.38
|
| Rate for Payer: NAPHCARE Commercial |
$1,770.29
|
| Rate for Payer: Preferred Network Access Commercial |
$2,714.44
|
| Rate for Payer: Quartz Beloit One Network |
$1,445.74
|
| Rate for Payer: Quartz Commercial |
$1,917.81
|
| Rate for Payer: Quartz Medicare Advantage |
$1,770.29
|
| Rate for Payer: The Alliance Commercial |
$1,475.24
|
| Rate for Payer: WEA Trust Commercial |
$1,622.76
|
| Rate for Payer: WPS Commercial |
$2,185.34
|
|
|
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 |
$768.48 |
| Max. Negotiated Rate |
$2,525.00 |
| Rate for Payer: Aetna Commercial |
$2,470.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,360.32
|
| Rate for Payer: Aetna Managed Medicare |
$768.48
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,783.96
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,372.28
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,317.39
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,454.62
|
| Rate for Payer: Cash Price |
$791.70
|
| Rate for Payer: Cigna Commercial |
$2,525.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,535.90
|
| Rate for Payer: Health EOS Commercial |
$2,442.66
|
| Rate for Payer: HFN Commercial |
$2,525.00
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,058.42
|
| Rate for Payer: Multiplan Commercial |
$2,195.65
|
| Rate for Payer: NAPHCARE Commercial |
$1,646.74
|
| Rate for Payer: Preferred Network Access Commercial |
$2,525.00
|
| Rate for Payer: Quartz Beloit One Network |
$1,344.83
|
| Rate for Payer: Quartz Commercial |
$1,783.96
|
| Rate for Payer: Quartz Medicare Advantage |
$1,646.74
|
| Rate for Payer: The Alliance Commercial |
$1,372.28
|
| Rate for Payer: WEA Trust Commercial |
$1,509.51
|
| Rate for Payer: WPS Commercial |
$2,032.82
|
|
|
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 |
$1,344.83 |
| Max. Negotiated Rate |
$2,525.00 |
| Rate for Payer: Aetna Commercial |
$2,470.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,360.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,454.62
|
| Rate for Payer: Cash Price |
$791.70
|
| Rate for Payer: Cigna Commercial |
$2,525.00
|
| Rate for Payer: Health EOS Commercial |
$2,442.66
|
| Rate for Payer: HFN Commercial |
$2,525.00
|
| Rate for Payer: Multiplan Commercial |
$2,195.65
|
| Rate for Payer: Preferred Network Access Commercial |
$2,525.00
|
| Rate for Payer: Quartz Beloit One Network |
$1,344.83
|
| Rate for Payer: Quartz Commercial |
$1,646.74
|
| Rate for Payer: WEA Trust Commercial |
$1,509.51
|
| Rate for Payer: WPS Commercial |
$2,032.82
|
|
|
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 |
$768.48 |
| Max. Negotiated Rate |
$2,525.00 |
| Rate for Payer: Aetna Commercial |
$2,470.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,360.32
|
| Rate for Payer: Aetna Managed Medicare |
$768.48
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,783.96
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,372.28
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,317.39
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,454.62
|
| Rate for Payer: Cash Price |
$791.70
|
| Rate for Payer: Cigna Commercial |
$2,525.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,535.90
|
| Rate for Payer: Health EOS Commercial |
$2,442.66
|
| Rate for Payer: HFN Commercial |
$2,525.00
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,058.42
|
| Rate for Payer: Multiplan Commercial |
$2,195.65
|
| Rate for Payer: NAPHCARE Commercial |
$1,646.74
|
| Rate for Payer: Preferred Network Access Commercial |
$2,525.00
|
| Rate for Payer: Quartz Beloit One Network |
$1,344.83
|
| Rate for Payer: Quartz Commercial |
$1,783.96
|
| Rate for Payer: Quartz Medicare Advantage |
$1,646.74
|
| Rate for Payer: The Alliance Commercial |
$1,372.28
|
| Rate for Payer: WEA Trust Commercial |
$1,509.51
|
| Rate for Payer: WPS Commercial |
$2,032.82
|
|
|
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 |
$1,344.83 |
| Max. Negotiated Rate |
$2,525.00 |
| Rate for Payer: Aetna Commercial |
$2,470.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,360.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,454.62
|
| Rate for Payer: Cash Price |
$791.70
|
| Rate for Payer: Cigna Commercial |
$2,525.00
|
| Rate for Payer: Health EOS Commercial |
$2,442.66
|
| Rate for Payer: HFN Commercial |
$2,525.00
|
| Rate for Payer: Multiplan Commercial |
$2,195.65
|
| Rate for Payer: Preferred Network Access Commercial |
$2,525.00
|
| Rate for Payer: Quartz Beloit One Network |
$1,344.83
|
| Rate for Payer: Quartz Commercial |
$1,646.74
|
| Rate for Payer: WEA Trust Commercial |
$1,509.51
|
| Rate for Payer: WPS Commercial |
$2,032.82
|
|
|
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 |
$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 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 |
$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
|
|
