|
BALLOON EMERGE MR 3.5 X 30 391893035
|
Facility
|
IP
|
$2,287.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
3072595
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,120.63 |
| Max. Negotiated Rate |
$2,104.04 |
| Rate for Payer: Aetna Commercial |
$2,058.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,966.82
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,212.11
|
| Rate for Payer: Cash Price |
$686.10
|
| Rate for Payer: Cigna Commercial |
$2,104.04
|
| Rate for Payer: Health EOS Commercial |
$2,035.43
|
| Rate for Payer: HFN Commercial |
$2,104.04
|
| Rate for Payer: Multiplan Commercial |
$1,829.60
|
| Rate for Payer: NAPHCARE Commercial |
$1,372.20
|
| Rate for Payer: Preferred Network Access Commercial |
$2,104.04
|
| Rate for Payer: Quartz Beloit One Network |
$1,120.63
|
| Rate for Payer: Quartz Commercial |
$1,372.20
|
| Rate for Payer: WEA Trust Commercial |
$1,257.85
|
| Rate for Payer: WPS Commercial |
$1,693.98
|
|
|
BALLOON EMERGE MR 3.5 X 30 391893035
|
Facility
|
OP
|
$2,287.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
3072595
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$640.36 |
| Max. Negotiated Rate |
$9,148.00 |
| Rate for Payer: Aetna Commercial |
$2,058.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,966.82
|
| Rate for Payer: Aetna Managed Medicare |
$640.36
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,486.55
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,143.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,097.76
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,212.11
|
| Rate for Payer: Cash Price |
$686.10
|
| Rate for Payer: Cigna Commercial |
$2,104.04
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,279.81
|
| Rate for Payer: Health EOS Commercial |
$2,035.43
|
| Rate for Payer: HFN Commercial |
$2,104.04
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,715.25
|
| Rate for Payer: Multiplan Commercial |
$1,829.60
|
| Rate for Payer: NAPHCARE Commercial |
$1,372.20
|
| Rate for Payer: Preferred Network Access Commercial |
$2,104.04
|
| Rate for Payer: Quartz Beloit One Network |
$1,120.63
|
| Rate for Payer: Quartz Commercial |
$1,486.55
|
| Rate for Payer: Quartz Medicare Advantage |
$1,372.20
|
| Rate for Payer: The Alliance Commercial |
$9,148.00
|
| Rate for Payer: WEA Trust Commercial |
$1,257.85
|
| Rate for Payer: WPS Commercial |
$1,693.98
|
|
|
BALLOON EMERGE MR 3.5 X 8 391890835
|
Facility
|
OP
|
$2,287.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
3072579
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$640.36 |
| Max. Negotiated Rate |
$9,148.00 |
| Rate for Payer: Aetna Commercial |
$2,058.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,966.82
|
| Rate for Payer: Aetna Managed Medicare |
$640.36
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,486.55
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,143.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,097.76
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,212.11
|
| Rate for Payer: Cash Price |
$686.10
|
| Rate for Payer: Cigna Commercial |
$2,104.04
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,279.81
|
| Rate for Payer: Health EOS Commercial |
$2,035.43
|
| Rate for Payer: HFN Commercial |
$2,104.04
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,715.25
|
| Rate for Payer: Multiplan Commercial |
$1,829.60
|
| Rate for Payer: NAPHCARE Commercial |
$1,372.20
|
| Rate for Payer: Preferred Network Access Commercial |
$2,104.04
|
| Rate for Payer: Quartz Beloit One Network |
$1,120.63
|
| Rate for Payer: Quartz Commercial |
$1,486.55
|
| Rate for Payer: Quartz Medicare Advantage |
$1,372.20
|
| Rate for Payer: The Alliance Commercial |
$9,148.00
|
| Rate for Payer: WEA Trust Commercial |
$1,257.85
|
| Rate for Payer: WPS Commercial |
$1,693.98
|
|
|
BALLOON EMERGE MR 3.5 X 8 391890835
|
Facility
|
IP
|
$2,287.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
3072579
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,120.63 |
| Max. Negotiated Rate |
$2,104.04 |
| Rate for Payer: Aetna Commercial |
$2,058.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,966.82
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,212.11
|
| Rate for Payer: Cash Price |
$686.10
|
| Rate for Payer: Cigna Commercial |
$2,104.04
|
| Rate for Payer: Health EOS Commercial |
$2,035.43
|
| Rate for Payer: HFN Commercial |
$2,104.04
|
| Rate for Payer: Multiplan Commercial |
$1,829.60
|
| Rate for Payer: NAPHCARE Commercial |
$1,372.20
|
| Rate for Payer: Preferred Network Access Commercial |
$2,104.04
|
| Rate for Payer: Quartz Beloit One Network |
$1,120.63
|
| Rate for Payer: Quartz Commercial |
$1,372.20
|
| Rate for Payer: WEA Trust Commercial |
$1,257.85
|
| Rate for Payer: WPS Commercial |
$1,693.98
|
|
|
BALLOON EMERGE MR 4.0 X 15 391891540
|
Facility
|
IP
|
$2,287.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
3072586
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,120.63 |
| Max. Negotiated Rate |
$2,104.04 |
| Rate for Payer: Aetna Commercial |
$2,058.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,966.82
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,212.11
|
| Rate for Payer: Cash Price |
$686.10
|
| Rate for Payer: Cigna Commercial |
$2,104.04
|
| Rate for Payer: Health EOS Commercial |
$2,035.43
|
| Rate for Payer: HFN Commercial |
$2,104.04
|
| Rate for Payer: Multiplan Commercial |
$1,829.60
|
| Rate for Payer: NAPHCARE Commercial |
$1,372.20
|
| Rate for Payer: Preferred Network Access Commercial |
$2,104.04
|
| Rate for Payer: Quartz Beloit One Network |
$1,120.63
|
| Rate for Payer: Quartz Commercial |
$1,372.20
|
| Rate for Payer: WEA Trust Commercial |
$1,257.85
|
| Rate for Payer: WPS Commercial |
$1,693.98
|
|
|
BALLOON EMERGE MR 4.0 X 15 391891540
|
Facility
|
OP
|
$2,287.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
3072586
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$640.36 |
| Max. Negotiated Rate |
$9,148.00 |
| Rate for Payer: Aetna Commercial |
$2,058.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,966.82
|
| Rate for Payer: Aetna Managed Medicare |
$640.36
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,486.55
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,143.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,097.76
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,212.11
|
| Rate for Payer: Cash Price |
$686.10
|
| Rate for Payer: Cigna Commercial |
$2,104.04
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,279.81
|
| Rate for Payer: Health EOS Commercial |
$2,035.43
|
| Rate for Payer: HFN Commercial |
$2,104.04
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,715.25
|
| Rate for Payer: Multiplan Commercial |
$1,829.60
|
| Rate for Payer: NAPHCARE Commercial |
$1,372.20
|
| Rate for Payer: Preferred Network Access Commercial |
$2,104.04
|
| Rate for Payer: Quartz Beloit One Network |
$1,120.63
|
| Rate for Payer: Quartz Commercial |
$1,486.55
|
| Rate for Payer: Quartz Medicare Advantage |
$1,372.20
|
| Rate for Payer: The Alliance Commercial |
$9,148.00
|
| Rate for Payer: WEA Trust Commercial |
$1,257.85
|
| Rate for Payer: WPS Commercial |
$1,693.98
|
|
|
BALLOON EMERGE MR 4.0 X 20 391892040
|
Facility
|
IP
|
$2,287.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
3072591
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,120.63 |
| Max. Negotiated Rate |
$2,104.04 |
| Rate for Payer: Aetna Commercial |
$2,058.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,966.82
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,212.11
|
| Rate for Payer: Cash Price |
$686.10
|
| Rate for Payer: Cigna Commercial |
$2,104.04
|
| Rate for Payer: Health EOS Commercial |
$2,035.43
|
| Rate for Payer: HFN Commercial |
$2,104.04
|
| Rate for Payer: Multiplan Commercial |
$1,829.60
|
| Rate for Payer: NAPHCARE Commercial |
$1,372.20
|
| Rate for Payer: Preferred Network Access Commercial |
$2,104.04
|
| Rate for Payer: Quartz Beloit One Network |
$1,120.63
|
| Rate for Payer: Quartz Commercial |
$1,372.20
|
| Rate for Payer: WEA Trust Commercial |
$1,257.85
|
| Rate for Payer: WPS Commercial |
$1,693.98
|
|
|
BALLOON EMERGE MR 4.0 X 20 391892040
|
Facility
|
OP
|
$2,287.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
3072591
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$640.36 |
| Max. Negotiated Rate |
$9,148.00 |
| Rate for Payer: Aetna Commercial |
$2,058.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,966.82
|
| Rate for Payer: Aetna Managed Medicare |
$640.36
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,486.55
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,143.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,097.76
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,212.11
|
| Rate for Payer: Cash Price |
$686.10
|
| Rate for Payer: Cigna Commercial |
$2,104.04
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,279.81
|
| Rate for Payer: Health EOS Commercial |
$2,035.43
|
| Rate for Payer: HFN Commercial |
$2,104.04
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,715.25
|
| Rate for Payer: Multiplan Commercial |
$1,829.60
|
| Rate for Payer: NAPHCARE Commercial |
$1,372.20
|
| Rate for Payer: Preferred Network Access Commercial |
$2,104.04
|
| Rate for Payer: Quartz Beloit One Network |
$1,120.63
|
| Rate for Payer: Quartz Commercial |
$1,486.55
|
| Rate for Payer: Quartz Medicare Advantage |
$1,372.20
|
| Rate for Payer: The Alliance Commercial |
$9,148.00
|
| Rate for Payer: WEA Trust Commercial |
$1,257.85
|
| Rate for Payer: WPS Commercial |
$1,693.98
|
|
|
BALLOON EMERGE MR 4.0 X 8 391890840
|
Facility
|
OP
|
$2,287.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
3072580
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$640.36 |
| Max. Negotiated Rate |
$9,148.00 |
| Rate for Payer: Aetna Commercial |
$2,058.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,966.82
|
| Rate for Payer: Aetna Managed Medicare |
$640.36
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,486.55
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,143.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,097.76
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,212.11
|
| Rate for Payer: Cash Price |
$686.10
|
| Rate for Payer: Cigna Commercial |
$2,104.04
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,279.81
|
| Rate for Payer: Health EOS Commercial |
$2,035.43
|
| Rate for Payer: HFN Commercial |
$2,104.04
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,715.25
|
| Rate for Payer: Multiplan Commercial |
$1,829.60
|
| Rate for Payer: NAPHCARE Commercial |
$1,372.20
|
| Rate for Payer: Preferred Network Access Commercial |
$2,104.04
|
| Rate for Payer: Quartz Beloit One Network |
$1,120.63
|
| Rate for Payer: Quartz Commercial |
$1,486.55
|
| Rate for Payer: Quartz Medicare Advantage |
$1,372.20
|
| Rate for Payer: The Alliance Commercial |
$9,148.00
|
| Rate for Payer: WEA Trust Commercial |
$1,257.85
|
| Rate for Payer: WPS Commercial |
$1,693.98
|
|
|
BALLOON EMERGE MR 4.0 X 8 391890840
|
Facility
|
IP
|
$2,287.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
3072580
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,120.63 |
| Max. Negotiated Rate |
$2,104.04 |
| Rate for Payer: Aetna Commercial |
$2,058.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,966.82
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,212.11
|
| Rate for Payer: Cash Price |
$686.10
|
| Rate for Payer: Cigna Commercial |
$2,104.04
|
| Rate for Payer: Health EOS Commercial |
$2,035.43
|
| Rate for Payer: HFN Commercial |
$2,104.04
|
| Rate for Payer: Multiplan Commercial |
$1,829.60
|
| Rate for Payer: NAPHCARE Commercial |
$1,372.20
|
| Rate for Payer: Preferred Network Access Commercial |
$2,104.04
|
| Rate for Payer: Quartz Beloit One Network |
$1,120.63
|
| Rate for Payer: Quartz Commercial |
$1,372.20
|
| Rate for Payer: WEA Trust Commercial |
$1,257.85
|
| Rate for Payer: WPS Commercial |
$1,693.98
|
|
|
BALLOON EVERCROSS 3.0 x 60mm
|
Facility
|
OP
|
$1,708.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
2972482
|
|
Hospital Revenue Code
|
278
|
| 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 EVERCROSS 3.0 x 60mm
|
Facility
|
IP
|
$1,708.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
2972482
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$836.92 |
| Max. Negotiated Rate |
$1,571.36 |
| Rate for Payer: Aetna Commercial |
$1,537.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,468.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$905.24
|
| Rate for Payer: Cash Price |
$512.40
|
| Rate for Payer: Cigna Commercial |
$1,571.36
|
| Rate for Payer: Health EOS Commercial |
$1,520.12
|
| Rate for Payer: HFN Commercial |
$1,571.36
|
| Rate for Payer: Multiplan Commercial |
$1,366.40
|
| Rate for Payer: NAPHCARE Commercial |
$1,024.80
|
| Rate for Payer: Preferred Network Access Commercial |
$1,571.36
|
| Rate for Payer: Quartz Beloit One Network |
$836.92
|
| Rate for Payer: Quartz Commercial |
$1,024.80
|
| Rate for Payer: WEA Trust Commercial |
$939.40
|
| Rate for Payer: WPS Commercial |
$1,265.12
|
|
|
BALLOON EVERCROSS 9mm X 80mm
|
Facility
|
OP
|
$2,288.00
|
|
|
Service Code
|
HCPCS C2628
|
| Hospital Charge Code |
2972935
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$640.64 |
| Max. Negotiated Rate |
$9,152.00 |
| Rate for Payer: Aetna Commercial |
$2,059.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,967.68
|
| Rate for Payer: Aetna Managed Medicare |
$640.64
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,487.20
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,144.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,098.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,212.64
|
| Rate for Payer: Cash Price |
$686.40
|
| Rate for Payer: Cigna Commercial |
$2,104.96
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,280.36
|
| Rate for Payer: Health EOS Commercial |
$2,036.32
|
| Rate for Payer: HFN Commercial |
$2,104.96
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,716.00
|
| Rate for Payer: Multiplan Commercial |
$1,830.40
|
| Rate for Payer: NAPHCARE Commercial |
$1,372.80
|
| Rate for Payer: Preferred Network Access Commercial |
$2,104.96
|
| Rate for Payer: Quartz Beloit One Network |
$1,121.12
|
| Rate for Payer: Quartz Commercial |
$1,487.20
|
| Rate for Payer: Quartz Medicare Advantage |
$1,372.80
|
| Rate for Payer: The Alliance Commercial |
$9,152.00
|
| Rate for Payer: WEA Trust Commercial |
$1,258.40
|
| Rate for Payer: WPS Commercial |
$1,694.72
|
|
|
BALLOON EVERCROSS 9mm X 80mm
|
Facility
|
IP
|
$2,288.00
|
|
|
Service Code
|
HCPCS C2628
|
| Hospital Charge Code |
2972935
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,121.12 |
| Max. Negotiated Rate |
$2,104.96 |
| Rate for Payer: Aetna Commercial |
$2,059.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,967.68
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,212.64
|
| Rate for Payer: Cash Price |
$686.40
|
| Rate for Payer: Cigna Commercial |
$2,104.96
|
| Rate for Payer: Health EOS Commercial |
$2,036.32
|
| Rate for Payer: HFN Commercial |
$2,104.96
|
| Rate for Payer: Multiplan Commercial |
$1,830.40
|
| Rate for Payer: NAPHCARE Commercial |
$1,372.80
|
| Rate for Payer: Preferred Network Access Commercial |
$2,104.96
|
| Rate for Payer: Quartz Beloit One Network |
$1,121.12
|
| Rate for Payer: Quartz Commercial |
$1,372.80
|
| Rate for Payer: WEA Trust Commercial |
$1,258.40
|
| Rate for Payer: WPS Commercial |
$1,694.72
|
|
|
BALLOON EXTRACTOR 12-15mm M00547010
|
Facility
|
IP
|
$2,297.00
|
|
|
Service Code
|
HCPCS A4649
|
| Hospital Charge Code |
2972909
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,125.53 |
| Max. Negotiated Rate |
$2,113.24 |
| Rate for Payer: Aetna Commercial |
$2,067.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,975.42
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,217.41
|
| Rate for Payer: Cash Price |
$689.10
|
| Rate for Payer: Cigna Commercial |
$2,113.24
|
| Rate for Payer: Health EOS Commercial |
$2,044.33
|
| Rate for Payer: HFN Commercial |
$2,113.24
|
| Rate for Payer: Multiplan Commercial |
$1,837.60
|
| Rate for Payer: NAPHCARE Commercial |
$1,378.20
|
| Rate for Payer: Preferred Network Access Commercial |
$2,113.24
|
| Rate for Payer: Quartz Beloit One Network |
$1,125.53
|
| Rate for Payer: Quartz Commercial |
$1,378.20
|
| Rate for Payer: WEA Trust Commercial |
$1,263.35
|
| Rate for Payer: WPS Commercial |
$1,701.39
|
|
|
BALLOON EXTRACTOR 12-15mm M00547010
|
Facility
|
OP
|
$2,297.00
|
|
|
Service Code
|
HCPCS A4649
|
| Hospital Charge Code |
2972909
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$643.16 |
| Max. Negotiated Rate |
$9,188.00 |
| Rate for Payer: Aetna Commercial |
$2,067.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,975.42
|
| Rate for Payer: Aetna Managed Medicare |
$643.16
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,493.05
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,148.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,102.56
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,217.41
|
| Rate for Payer: Cash Price |
$689.10
|
| Rate for Payer: Cigna Commercial |
$2,113.24
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,285.40
|
| Rate for Payer: Health EOS Commercial |
$2,044.33
|
| Rate for Payer: HFN Commercial |
$2,113.24
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,722.75
|
| Rate for Payer: Multiplan Commercial |
$1,837.60
|
| Rate for Payer: NAPHCARE Commercial |
$1,378.20
|
| Rate for Payer: Preferred Network Access Commercial |
$2,113.24
|
| Rate for Payer: Quartz Beloit One Network |
$1,125.53
|
| Rate for Payer: Quartz Commercial |
$1,493.05
|
| Rate for Payer: Quartz Medicare Advantage |
$1,378.20
|
| Rate for Payer: The Alliance Commercial |
$9,188.00
|
| Rate for Payer: WEA Trust Commercial |
$1,263.35
|
| Rate for Payer: WPS Commercial |
$1,701.39
|
|
|
BALLOON EXTRACTOR 15-18mm 4702
|
Facility
|
OP
|
$2,298.00
|
|
|
Service Code
|
HCPCS C1726
|
| Hospital Charge Code |
3211484
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$643.44 |
| Max. Negotiated Rate |
$9,192.00 |
| Rate for Payer: Aetna Commercial |
$2,068.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,976.28
|
| Rate for Payer: Aetna Managed Medicare |
$643.44
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,493.70
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,149.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,103.04
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,217.94
|
| Rate for Payer: Cash Price |
$689.40
|
| Rate for Payer: Cigna Commercial |
$2,114.16
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,285.96
|
| Rate for Payer: Health EOS Commercial |
$2,045.22
|
| Rate for Payer: HFN Commercial |
$2,114.16
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,723.50
|
| Rate for Payer: Multiplan Commercial |
$1,838.40
|
| Rate for Payer: NAPHCARE Commercial |
$1,378.80
|
| Rate for Payer: Preferred Network Access Commercial |
$2,114.16
|
| Rate for Payer: Quartz Beloit One Network |
$1,126.02
|
| Rate for Payer: Quartz Commercial |
$1,493.70
|
| Rate for Payer: Quartz Medicare Advantage |
$1,378.80
|
| Rate for Payer: The Alliance Commercial |
$9,192.00
|
| Rate for Payer: WEA Trust Commercial |
$1,263.90
|
| Rate for Payer: WPS Commercial |
$1,702.13
|
|
|
BALLOON EXTRACTOR 15-18mm 4702
|
Facility
|
IP
|
$2,298.00
|
|
|
Service Code
|
HCPCS C1726
|
| Hospital Charge Code |
3211484
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,126.02 |
| Max. Negotiated Rate |
$2,114.16 |
| Rate for Payer: Aetna Commercial |
$2,068.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,976.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,217.94
|
| Rate for Payer: Cash Price |
$689.40
|
| Rate for Payer: Cigna Commercial |
$2,114.16
|
| Rate for Payer: Health EOS Commercial |
$2,045.22
|
| Rate for Payer: HFN Commercial |
$2,114.16
|
| Rate for Payer: Multiplan Commercial |
$1,838.40
|
| Rate for Payer: NAPHCARE Commercial |
$1,378.80
|
| Rate for Payer: Preferred Network Access Commercial |
$2,114.16
|
| Rate for Payer: Quartz Beloit One Network |
$1,126.02
|
| Rate for Payer: Quartz Commercial |
$1,378.80
|
| Rate for Payer: WEA Trust Commercial |
$1,263.90
|
| Rate for Payer: WPS Commercial |
$1,702.13
|
|
|
BALLOON EXTRACTOR 9-12mm M00547000
|
Facility
|
OP
|
$2,297.00
|
|
|
Service Code
|
HCPCS A4649
|
| Hospital Charge Code |
2972908
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$643.16 |
| Max. Negotiated Rate |
$9,188.00 |
| Rate for Payer: Aetna Commercial |
$2,067.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,975.42
|
| Rate for Payer: Aetna Managed Medicare |
$643.16
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,493.05
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,148.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,102.56
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,217.41
|
| Rate for Payer: Cash Price |
$689.10
|
| Rate for Payer: Cigna Commercial |
$2,113.24
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,285.40
|
| Rate for Payer: Health EOS Commercial |
$2,044.33
|
| Rate for Payer: HFN Commercial |
$2,113.24
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,722.75
|
| Rate for Payer: Multiplan Commercial |
$1,837.60
|
| Rate for Payer: NAPHCARE Commercial |
$1,378.20
|
| Rate for Payer: Preferred Network Access Commercial |
$2,113.24
|
| Rate for Payer: Quartz Beloit One Network |
$1,125.53
|
| Rate for Payer: Quartz Commercial |
$1,493.05
|
| Rate for Payer: Quartz Medicare Advantage |
$1,378.20
|
| Rate for Payer: The Alliance Commercial |
$9,188.00
|
| Rate for Payer: WEA Trust Commercial |
$1,263.35
|
| Rate for Payer: WPS Commercial |
$1,701.39
|
|
|
BALLOON EXTRACTOR 9-12mm M00547000
|
Facility
|
IP
|
$2,297.00
|
|
|
Service Code
|
HCPCS A4649
|
| Hospital Charge Code |
2972908
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,125.53 |
| Max. Negotiated Rate |
$2,113.24 |
| Rate for Payer: Aetna Commercial |
$2,067.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,975.42
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,217.41
|
| Rate for Payer: Cash Price |
$689.10
|
| Rate for Payer: Cigna Commercial |
$2,113.24
|
| Rate for Payer: Health EOS Commercial |
$2,044.33
|
| Rate for Payer: HFN Commercial |
$2,113.24
|
| Rate for Payer: Multiplan Commercial |
$1,837.60
|
| Rate for Payer: NAPHCARE Commercial |
$1,378.20
|
| Rate for Payer: Preferred Network Access Commercial |
$2,113.24
|
| Rate for Payer: Quartz Beloit One Network |
$1,125.53
|
| Rate for Payer: Quartz Commercial |
$1,378.20
|
| Rate for Payer: WEA Trust Commercial |
$1,263.35
|
| Rate for Payer: WPS Commercial |
$1,701.39
|
|
|
BALLOON FLEXTOME 2.00x15mm CUTTING-RX
|
Facility
|
IP
|
$1,904.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
3107496
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$932.96 |
| Max. Negotiated Rate |
$1,751.68 |
| Rate for Payer: Aetna Commercial |
$1,713.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,637.44
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,009.12
|
| Rate for Payer: Cash Price |
$571.20
|
| Rate for Payer: Cigna Commercial |
$1,751.68
|
| Rate for Payer: Health EOS Commercial |
$1,694.56
|
| Rate for Payer: HFN Commercial |
$1,751.68
|
| Rate for Payer: Multiplan Commercial |
$1,523.20
|
| Rate for Payer: NAPHCARE Commercial |
$1,142.40
|
| Rate for Payer: Preferred Network Access Commercial |
$1,751.68
|
| Rate for Payer: Quartz Beloit One Network |
$932.96
|
| Rate for Payer: Quartz Commercial |
$1,142.40
|
| Rate for Payer: WEA Trust Commercial |
$1,047.20
|
| Rate for Payer: WPS Commercial |
$1,410.29
|
|
|
BALLOON FLEXTOME 2.00x15mm CUTTING-RX
|
Facility
|
OP
|
$1,904.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
3107496
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$533.12 |
| Max. Negotiated Rate |
$7,616.00 |
| Rate for Payer: Aetna Commercial |
$1,713.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,637.44
|
| Rate for Payer: Aetna Managed Medicare |
$533.12
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,237.60
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$952.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$913.92
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,009.12
|
| Rate for Payer: Cash Price |
$571.20
|
| Rate for Payer: Cigna Commercial |
$1,751.68
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,065.48
|
| Rate for Payer: Health EOS Commercial |
$1,694.56
|
| Rate for Payer: HFN Commercial |
$1,751.68
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,428.00
|
| Rate for Payer: Multiplan Commercial |
$1,523.20
|
| Rate for Payer: NAPHCARE Commercial |
$1,142.40
|
| Rate for Payer: Preferred Network Access Commercial |
$1,751.68
|
| Rate for Payer: Quartz Beloit One Network |
$932.96
|
| Rate for Payer: Quartz Commercial |
$1,237.60
|
| Rate for Payer: Quartz Medicare Advantage |
$1,142.40
|
| Rate for Payer: The Alliance Commercial |
$7,616.00
|
| Rate for Payer: WEA Trust Commercial |
$1,047.20
|
| Rate for Payer: WPS Commercial |
$1,410.29
|
|
|
BALLOON FLEXTOME 2.5 X 15MM
|
Facility
|
IP
|
$6,401.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
3533501
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$3,136.49 |
| Max. Negotiated Rate |
$5,888.92 |
| Rate for Payer: Aetna Commercial |
$5,760.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,504.86
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,392.53
|
| Rate for Payer: Cash Price |
$1,920.30
|
| Rate for Payer: Cigna Commercial |
$5,888.92
|
| Rate for Payer: Health EOS Commercial |
$5,696.89
|
| Rate for Payer: HFN Commercial |
$5,888.92
|
| Rate for Payer: Multiplan Commercial |
$5,120.80
|
| Rate for Payer: NAPHCARE Commercial |
$3,840.60
|
| Rate for Payer: Preferred Network Access Commercial |
$5,888.92
|
| Rate for Payer: Quartz Beloit One Network |
$3,136.49
|
| Rate for Payer: Quartz Commercial |
$3,840.60
|
| Rate for Payer: WEA Trust Commercial |
$3,520.55
|
| Rate for Payer: WPS Commercial |
$4,741.22
|
|
|
BALLOON FLEXTOME 2.5 X 15MM
|
Facility
|
OP
|
$6,401.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
3533501
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,792.28 |
| Max. Negotiated Rate |
$25,604.00 |
| Rate for Payer: Aetna Commercial |
$5,760.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,504.86
|
| Rate for Payer: Aetna Managed Medicare |
$1,792.28
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,160.65
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,200.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,072.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,392.53
|
| Rate for Payer: Cash Price |
$1,920.30
|
| Rate for Payer: Cigna Commercial |
$5,888.92
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,582.00
|
| Rate for Payer: Health EOS Commercial |
$5,696.89
|
| Rate for Payer: HFN Commercial |
$5,888.92
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,800.75
|
| Rate for Payer: Multiplan Commercial |
$5,120.80
|
| Rate for Payer: NAPHCARE Commercial |
$3,840.60
|
| Rate for Payer: Preferred Network Access Commercial |
$5,888.92
|
| Rate for Payer: Quartz Beloit One Network |
$3,136.49
|
| Rate for Payer: Quartz Commercial |
$4,160.65
|
| Rate for Payer: Quartz Medicare Advantage |
$3,840.60
|
| Rate for Payer: The Alliance Commercial |
$25,604.00
|
| Rate for Payer: WEA Trust Commercial |
$3,520.55
|
| Rate for Payer: WPS Commercial |
$4,741.22
|
|
|
BALLOON FLEXTOME CUTTING 3.0 X 15MM #CBM330015
|
Facility
|
IP
|
$1,904.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
3107477
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$932.96 |
| Max. Negotiated Rate |
$1,751.68 |
| Rate for Payer: Aetna Commercial |
$1,713.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,637.44
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,009.12
|
| Rate for Payer: Cash Price |
$571.20
|
| Rate for Payer: Cigna Commercial |
$1,751.68
|
| Rate for Payer: Health EOS Commercial |
$1,694.56
|
| Rate for Payer: HFN Commercial |
$1,751.68
|
| Rate for Payer: Multiplan Commercial |
$1,523.20
|
| Rate for Payer: NAPHCARE Commercial |
$1,142.40
|
| Rate for Payer: Preferred Network Access Commercial |
$1,751.68
|
| Rate for Payer: Quartz Beloit One Network |
$932.96
|
| Rate for Payer: Quartz Commercial |
$1,142.40
|
| Rate for Payer: WEA Trust Commercial |
$1,047.20
|
| Rate for Payer: WPS Commercial |
$1,410.29
|
|
