|
BALLOON FLEXTOME CUTTING 3.0 X 15MM #CBM330015
|
Facility
|
OP
|
$1,904.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
3107477
|
|
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 CUTTING RX 2.5 x 10mm #CBM325010
|
Facility
|
OP
|
$1,904.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
3107493
|
|
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 CUTTING RX 2.5 x 10mm #CBM325010
|
Facility
|
IP
|
$1,904.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
3107493
|
|
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 CUTTING RX 3.0 x 10mm #CBM330010
|
Facility
|
IP
|
$1,904.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
3107494
|
|
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 CUTTING RX 3.0 x 10mm #CBM330010
|
Facility
|
OP
|
$1,904.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
3107494
|
|
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 CUTTING RX 3.5 x 10mm #CBM335010
|
Facility
|
IP
|
$1,904.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
3107495
|
|
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 CUTTING RX 3.5 x 10mm #CBM335010
|
Facility
|
OP
|
$1,904.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
3107495
|
|
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 ULTRA2 CUTTING 2.0x10
|
Facility
|
IP
|
$1,904.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
3107476
|
|
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 ULTRA2 CUTTING 2.0x10
|
Facility
|
OP
|
$1,904.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
3107476
|
|
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 I/A 8FR 50cc W/STATLOCK (2)
|
Facility
|
IP
|
$8,800.00
|
|
|
Service Code
|
HCPCS C2628
|
| Hospital Charge Code |
2973735
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,312.00 |
| Max. Negotiated Rate |
$8,096.00 |
| Rate for Payer: Aetna Commercial |
$7,920.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,568.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,664.00
|
| Rate for Payer: Cash Price |
$2,640.00
|
| Rate for Payer: Cigna Commercial |
$8,096.00
|
| Rate for Payer: Health EOS Commercial |
$7,832.00
|
| Rate for Payer: HFN Commercial |
$8,096.00
|
| Rate for Payer: Multiplan Commercial |
$7,040.00
|
| Rate for Payer: NAPHCARE Commercial |
$5,280.00
|
| Rate for Payer: Preferred Network Access Commercial |
$8,096.00
|
| Rate for Payer: Quartz Beloit One Network |
$4,312.00
|
| Rate for Payer: Quartz Commercial |
$5,280.00
|
| Rate for Payer: WEA Trust Commercial |
$4,840.00
|
| Rate for Payer: WPS Commercial |
$6,518.16
|
|
|
BALLOON I/A 8FR 50cc W/STATLOCK (2)
|
Facility
|
OP
|
$8,800.00
|
|
|
Service Code
|
HCPCS C2628
|
| Hospital Charge Code |
2973735
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,464.00 |
| Max. Negotiated Rate |
$35,200.00 |
| Rate for Payer: Aetna Commercial |
$7,920.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,568.00
|
| Rate for Payer: Aetna Managed Medicare |
$2,464.00
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5,720.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,400.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,224.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,664.00
|
| Rate for Payer: Cash Price |
$2,640.00
|
| Rate for Payer: Cigna Commercial |
$8,096.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,924.48
|
| Rate for Payer: Health EOS Commercial |
$7,832.00
|
| Rate for Payer: HFN Commercial |
$8,096.00
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$6,600.00
|
| Rate for Payer: Multiplan Commercial |
$7,040.00
|
| Rate for Payer: NAPHCARE Commercial |
$5,280.00
|
| Rate for Payer: Preferred Network Access Commercial |
$8,096.00
|
| Rate for Payer: Quartz Beloit One Network |
$4,312.00
|
| Rate for Payer: Quartz Commercial |
$5,720.00
|
| Rate for Payer: Quartz Medicare Advantage |
$5,280.00
|
| Rate for Payer: The Alliance Commercial |
$35,200.00
|
| Rate for Payer: WEA Trust Commercial |
$4,840.00
|
| Rate for Payer: WPS Commercial |
$6,518.16
|
|
|
BALLOON MAVERICK MONORAIL 2.0 X 15mm
|
Facility
|
OP
|
$1,525.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
3393506
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$427.00 |
| Max. Negotiated Rate |
$6,100.00 |
| Rate for Payer: Aetna Commercial |
$1,372.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,311.50
|
| Rate for Payer: Aetna Managed Medicare |
$427.00
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$991.25
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$762.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$732.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$808.25
|
| Rate for Payer: Cash Price |
$457.50
|
| Rate for Payer: Cigna Commercial |
$1,403.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$853.39
|
| Rate for Payer: Health EOS Commercial |
$1,357.25
|
| Rate for Payer: HFN Commercial |
$1,403.00
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,143.75
|
| Rate for Payer: Multiplan Commercial |
$1,220.00
|
| Rate for Payer: NAPHCARE Commercial |
$915.00
|
| Rate for Payer: Preferred Network Access Commercial |
$1,403.00
|
| Rate for Payer: Quartz Beloit One Network |
$747.25
|
| Rate for Payer: Quartz Commercial |
$991.25
|
| Rate for Payer: Quartz Medicare Advantage |
$915.00
|
| Rate for Payer: The Alliance Commercial |
$6,100.00
|
| Rate for Payer: WEA Trust Commercial |
$838.75
|
| Rate for Payer: WPS Commercial |
$1,129.57
|
|
|
BALLOON MAVERICK MONORAIL 2.0 X 15mm
|
Facility
|
IP
|
$1,525.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
3393506
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$747.25 |
| Max. Negotiated Rate |
$1,403.00 |
| Rate for Payer: Aetna Commercial |
$1,372.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,311.50
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$808.25
|
| Rate for Payer: Cash Price |
$457.50
|
| Rate for Payer: Cigna Commercial |
$1,403.00
|
| Rate for Payer: Health EOS Commercial |
$1,357.25
|
| Rate for Payer: HFN Commercial |
$1,403.00
|
| Rate for Payer: Multiplan Commercial |
$1,220.00
|
| Rate for Payer: NAPHCARE Commercial |
$915.00
|
| Rate for Payer: Preferred Network Access Commercial |
$1,403.00
|
| Rate for Payer: Quartz Beloit One Network |
$747.25
|
| Rate for Payer: Quartz Commercial |
$915.00
|
| Rate for Payer: WEA Trust Commercial |
$838.75
|
| Rate for Payer: WPS Commercial |
$1,129.57
|
|
|
BALLOON MAVERICK MONORAIL 2.0 X 20mm
|
Facility
|
IP
|
$1,525.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
3393507
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$747.25 |
| Max. Negotiated Rate |
$1,403.00 |
| Rate for Payer: Aetna Commercial |
$1,372.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,311.50
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$808.25
|
| Rate for Payer: Cash Price |
$457.50
|
| Rate for Payer: Cigna Commercial |
$1,403.00
|
| Rate for Payer: Health EOS Commercial |
$1,357.25
|
| Rate for Payer: HFN Commercial |
$1,403.00
|
| Rate for Payer: Multiplan Commercial |
$1,220.00
|
| Rate for Payer: NAPHCARE Commercial |
$915.00
|
| Rate for Payer: Preferred Network Access Commercial |
$1,403.00
|
| Rate for Payer: Quartz Beloit One Network |
$747.25
|
| Rate for Payer: Quartz Commercial |
$915.00
|
| Rate for Payer: WEA Trust Commercial |
$838.75
|
| Rate for Payer: WPS Commercial |
$1,129.57
|
|
|
BALLOON MAVERICK MONORAIL 2.0 X 20mm
|
Facility
|
OP
|
$1,525.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
3393507
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$427.00 |
| Max. Negotiated Rate |
$6,100.00 |
| Rate for Payer: Aetna Commercial |
$1,372.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,311.50
|
| Rate for Payer: Aetna Managed Medicare |
$427.00
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$991.25
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$762.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$732.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$808.25
|
| Rate for Payer: Cash Price |
$457.50
|
| Rate for Payer: Cigna Commercial |
$1,403.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$853.39
|
| Rate for Payer: Health EOS Commercial |
$1,357.25
|
| Rate for Payer: HFN Commercial |
$1,403.00
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,143.75
|
| Rate for Payer: Multiplan Commercial |
$1,220.00
|
| Rate for Payer: NAPHCARE Commercial |
$915.00
|
| Rate for Payer: Preferred Network Access Commercial |
$1,403.00
|
| Rate for Payer: Quartz Beloit One Network |
$747.25
|
| Rate for Payer: Quartz Commercial |
$991.25
|
| Rate for Payer: Quartz Medicare Advantage |
$915.00
|
| Rate for Payer: The Alliance Commercial |
$6,100.00
|
| Rate for Payer: WEA Trust Commercial |
$838.75
|
| Rate for Payer: WPS Commercial |
$1,129.57
|
|
|
BALLOON MAVERICK MONORAIL 2.0 X 9mm
|
Facility
|
OP
|
$1,525.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
3393505
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$427.00 |
| Max. Negotiated Rate |
$6,100.00 |
| Rate for Payer: Aetna Commercial |
$1,372.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,311.50
|
| Rate for Payer: Aetna Managed Medicare |
$427.00
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$991.25
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$762.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$732.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$808.25
|
| Rate for Payer: Cash Price |
$457.50
|
| Rate for Payer: Cigna Commercial |
$1,403.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$853.39
|
| Rate for Payer: Health EOS Commercial |
$1,357.25
|
| Rate for Payer: HFN Commercial |
$1,403.00
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,143.75
|
| Rate for Payer: Multiplan Commercial |
$1,220.00
|
| Rate for Payer: NAPHCARE Commercial |
$915.00
|
| Rate for Payer: Preferred Network Access Commercial |
$1,403.00
|
| Rate for Payer: Quartz Beloit One Network |
$747.25
|
| Rate for Payer: Quartz Commercial |
$991.25
|
| Rate for Payer: Quartz Medicare Advantage |
$915.00
|
| Rate for Payer: The Alliance Commercial |
$6,100.00
|
| Rate for Payer: WEA Trust Commercial |
$838.75
|
| Rate for Payer: WPS Commercial |
$1,129.57
|
|
|
BALLOON MAVERICK MONORAIL 2.0 X 9mm
|
Facility
|
IP
|
$1,525.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
3393505
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$747.25 |
| Max. Negotiated Rate |
$1,403.00 |
| Rate for Payer: Aetna Commercial |
$1,372.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,311.50
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$808.25
|
| Rate for Payer: Cash Price |
$457.50
|
| Rate for Payer: Cigna Commercial |
$1,403.00
|
| Rate for Payer: Health EOS Commercial |
$1,357.25
|
| Rate for Payer: HFN Commercial |
$1,403.00
|
| Rate for Payer: Multiplan Commercial |
$1,220.00
|
| Rate for Payer: NAPHCARE Commercial |
$915.00
|
| Rate for Payer: Preferred Network Access Commercial |
$1,403.00
|
| Rate for Payer: Quartz Beloit One Network |
$747.25
|
| Rate for Payer: Quartz Commercial |
$915.00
|
| Rate for Payer: WEA Trust Commercial |
$838.75
|
| Rate for Payer: WPS Commercial |
$1,129.57
|
|
|
BALLOON MAVERICK MONORAIL 2.5 X 15mm
|
Facility
|
OP
|
$1,525.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
3171467
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$427.00 |
| Max. Negotiated Rate |
$6,100.00 |
| Rate for Payer: Aetna Commercial |
$1,372.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,311.50
|
| Rate for Payer: Aetna Managed Medicare |
$427.00
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$991.25
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$762.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$732.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$808.25
|
| Rate for Payer: Cash Price |
$457.50
|
| Rate for Payer: Cigna Commercial |
$1,403.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$853.39
|
| Rate for Payer: Health EOS Commercial |
$1,357.25
|
| Rate for Payer: HFN Commercial |
$1,403.00
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,143.75
|
| Rate for Payer: Multiplan Commercial |
$1,220.00
|
| Rate for Payer: NAPHCARE Commercial |
$915.00
|
| Rate for Payer: Preferred Network Access Commercial |
$1,403.00
|
| Rate for Payer: Quartz Beloit One Network |
$747.25
|
| Rate for Payer: Quartz Commercial |
$991.25
|
| Rate for Payer: Quartz Medicare Advantage |
$915.00
|
| Rate for Payer: The Alliance Commercial |
$6,100.00
|
| Rate for Payer: WEA Trust Commercial |
$838.75
|
| Rate for Payer: WPS Commercial |
$1,129.57
|
|
|
BALLOON MAVERICK MONORAIL 2.5 X 15mm
|
Facility
|
IP
|
$1,525.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
3171467
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$747.25 |
| Max. Negotiated Rate |
$1,403.00 |
| Rate for Payer: Aetna Commercial |
$1,372.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,311.50
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$808.25
|
| Rate for Payer: Cash Price |
$457.50
|
| Rate for Payer: Cigna Commercial |
$1,403.00
|
| Rate for Payer: Health EOS Commercial |
$1,357.25
|
| Rate for Payer: HFN Commercial |
$1,403.00
|
| Rate for Payer: Multiplan Commercial |
$1,220.00
|
| Rate for Payer: NAPHCARE Commercial |
$915.00
|
| Rate for Payer: Preferred Network Access Commercial |
$1,403.00
|
| Rate for Payer: Quartz Beloit One Network |
$747.25
|
| Rate for Payer: Quartz Commercial |
$915.00
|
| Rate for Payer: WEA Trust Commercial |
$838.75
|
| Rate for Payer: WPS Commercial |
$1,129.57
|
|
|
BALLOON MAVERICK MONORAIL 2.5 X 20mm
|
Facility
|
OP
|
$1,525.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
3171469
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$427.00 |
| Max. Negotiated Rate |
$6,100.00 |
| Rate for Payer: Aetna Commercial |
$1,372.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,311.50
|
| Rate for Payer: Aetna Managed Medicare |
$427.00
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$991.25
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$762.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$732.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$808.25
|
| Rate for Payer: Cash Price |
$457.50
|
| Rate for Payer: Cigna Commercial |
$1,403.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$853.39
|
| Rate for Payer: Health EOS Commercial |
$1,357.25
|
| Rate for Payer: HFN Commercial |
$1,403.00
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,143.75
|
| Rate for Payer: Multiplan Commercial |
$1,220.00
|
| Rate for Payer: NAPHCARE Commercial |
$915.00
|
| Rate for Payer: Preferred Network Access Commercial |
$1,403.00
|
| Rate for Payer: Quartz Beloit One Network |
$747.25
|
| Rate for Payer: Quartz Commercial |
$991.25
|
| Rate for Payer: Quartz Medicare Advantage |
$915.00
|
| Rate for Payer: The Alliance Commercial |
$6,100.00
|
| Rate for Payer: WEA Trust Commercial |
$838.75
|
| Rate for Payer: WPS Commercial |
$1,129.57
|
|
|
BALLOON MAVERICK MONORAIL 2.5 X 20mm
|
Facility
|
IP
|
$1,525.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
3171469
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$747.25 |
| Max. Negotiated Rate |
$1,403.00 |
| Rate for Payer: Aetna Commercial |
$1,372.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,311.50
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$808.25
|
| Rate for Payer: Cash Price |
$457.50
|
| Rate for Payer: Cigna Commercial |
$1,403.00
|
| Rate for Payer: Health EOS Commercial |
$1,357.25
|
| Rate for Payer: HFN Commercial |
$1,403.00
|
| Rate for Payer: Multiplan Commercial |
$1,220.00
|
| Rate for Payer: NAPHCARE Commercial |
$915.00
|
| Rate for Payer: Preferred Network Access Commercial |
$1,403.00
|
| Rate for Payer: Quartz Beloit One Network |
$747.25
|
| Rate for Payer: Quartz Commercial |
$915.00
|
| Rate for Payer: WEA Trust Commercial |
$838.75
|
| Rate for Payer: WPS Commercial |
$1,129.57
|
|
|
BALLOON MAVERICK MONORAIL 2.5 X 9mm
|
Facility
|
OP
|
$1,525.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
3393508
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$427.00 |
| Max. Negotiated Rate |
$6,100.00 |
| Rate for Payer: Aetna Commercial |
$1,372.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,311.50
|
| Rate for Payer: Aetna Managed Medicare |
$427.00
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$991.25
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$762.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$732.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$808.25
|
| Rate for Payer: Cash Price |
$457.50
|
| Rate for Payer: Cigna Commercial |
$1,403.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$853.39
|
| Rate for Payer: Health EOS Commercial |
$1,357.25
|
| Rate for Payer: HFN Commercial |
$1,403.00
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,143.75
|
| Rate for Payer: Multiplan Commercial |
$1,220.00
|
| Rate for Payer: NAPHCARE Commercial |
$915.00
|
| Rate for Payer: Preferred Network Access Commercial |
$1,403.00
|
| Rate for Payer: Quartz Beloit One Network |
$747.25
|
| Rate for Payer: Quartz Commercial |
$991.25
|
| Rate for Payer: Quartz Medicare Advantage |
$915.00
|
| Rate for Payer: The Alliance Commercial |
$6,100.00
|
| Rate for Payer: WEA Trust Commercial |
$838.75
|
| Rate for Payer: WPS Commercial |
$1,129.57
|
|
|
BALLOON MAVERICK MONORAIL 2.5 X 9mm
|
Facility
|
IP
|
$1,525.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
3393508
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$747.25 |
| Max. Negotiated Rate |
$1,403.00 |
| Rate for Payer: Aetna Commercial |
$1,372.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,311.50
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$808.25
|
| Rate for Payer: Cash Price |
$457.50
|
| Rate for Payer: Cigna Commercial |
$1,403.00
|
| Rate for Payer: Health EOS Commercial |
$1,357.25
|
| Rate for Payer: HFN Commercial |
$1,403.00
|
| Rate for Payer: Multiplan Commercial |
$1,220.00
|
| Rate for Payer: NAPHCARE Commercial |
$915.00
|
| Rate for Payer: Preferred Network Access Commercial |
$1,403.00
|
| Rate for Payer: Quartz Beloit One Network |
$747.25
|
| Rate for Payer: Quartz Commercial |
$915.00
|
| Rate for Payer: WEA Trust Commercial |
$838.75
|
| Rate for Payer: WPS Commercial |
$1,129.57
|
|
|
BALLOON MAVERICK MONORAIL 3.0 X 15mm
|
Facility
|
IP
|
$1,525.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
3171468
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$747.25 |
| Max. Negotiated Rate |
$1,403.00 |
| Rate for Payer: Aetna Commercial |
$1,372.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,311.50
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$808.25
|
| Rate for Payer: Cash Price |
$457.50
|
| Rate for Payer: Cigna Commercial |
$1,403.00
|
| Rate for Payer: Health EOS Commercial |
$1,357.25
|
| Rate for Payer: HFN Commercial |
$1,403.00
|
| Rate for Payer: Multiplan Commercial |
$1,220.00
|
| Rate for Payer: NAPHCARE Commercial |
$915.00
|
| Rate for Payer: Preferred Network Access Commercial |
$1,403.00
|
| Rate for Payer: Quartz Beloit One Network |
$747.25
|
| Rate for Payer: Quartz Commercial |
$915.00
|
| Rate for Payer: WEA Trust Commercial |
$838.75
|
| Rate for Payer: WPS Commercial |
$1,129.57
|
|
|
BALLOON MAVERICK MONORAIL 3.0 X 15mm
|
Facility
|
OP
|
$1,525.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
3171468
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$427.00 |
| Max. Negotiated Rate |
$6,100.00 |
| Rate for Payer: Aetna Commercial |
$1,372.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,311.50
|
| Rate for Payer: Aetna Managed Medicare |
$427.00
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$991.25
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$762.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$732.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$808.25
|
| Rate for Payer: Cash Price |
$457.50
|
| Rate for Payer: Cigna Commercial |
$1,403.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$853.39
|
| Rate for Payer: Health EOS Commercial |
$1,357.25
|
| Rate for Payer: HFN Commercial |
$1,403.00
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,143.75
|
| Rate for Payer: Multiplan Commercial |
$1,220.00
|
| Rate for Payer: NAPHCARE Commercial |
$915.00
|
| Rate for Payer: Preferred Network Access Commercial |
$1,403.00
|
| Rate for Payer: Quartz Beloit One Network |
$747.25
|
| Rate for Payer: Quartz Commercial |
$991.25
|
| Rate for Payer: Quartz Medicare Advantage |
$915.00
|
| Rate for Payer: The Alliance Commercial |
$6,100.00
|
| Rate for Payer: WEA Trust Commercial |
$838.75
|
| Rate for Payer: WPS Commercial |
$1,129.57
|
|
