|
BALLOON MUSTANG 5.0 x 20x 75cm
|
Facility
|
IP
|
$3,842.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
2973446
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,882.58 |
| Max. Negotiated Rate |
$3,534.64 |
| Rate for Payer: Aetna Commercial |
$3,457.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,304.12
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,036.26
|
| Rate for Payer: Cash Price |
$1,152.60
|
| Rate for Payer: Cigna Commercial |
$3,534.64
|
| Rate for Payer: Health EOS Commercial |
$3,419.38
|
| Rate for Payer: HFN Commercial |
$3,534.64
|
| Rate for Payer: Multiplan Commercial |
$3,073.60
|
| Rate for Payer: NAPHCARE Commercial |
$2,305.20
|
| Rate for Payer: Preferred Network Access Commercial |
$3,534.64
|
| Rate for Payer: Quartz Beloit One Network |
$1,882.58
|
| Rate for Payer: Quartz Commercial |
$2,305.20
|
| Rate for Payer: WEA Trust Commercial |
$2,113.10
|
| Rate for Payer: WPS Commercial |
$2,845.77
|
|
|
BALLOON MUSTANG 5 x 40x 40CM
|
Facility
|
IP
|
$3,956.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
3467506
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,938.44 |
| Max. Negotiated Rate |
$3,639.52 |
| Rate for Payer: Aetna Commercial |
$3,560.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,402.16
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,096.68
|
| Rate for Payer: Cash Price |
$1,186.80
|
| Rate for Payer: Cigna Commercial |
$3,639.52
|
| Rate for Payer: Health EOS Commercial |
$3,520.84
|
| Rate for Payer: HFN Commercial |
$3,639.52
|
| Rate for Payer: Multiplan Commercial |
$3,164.80
|
| Rate for Payer: NAPHCARE Commercial |
$2,373.60
|
| Rate for Payer: Preferred Network Access Commercial |
$3,639.52
|
| Rate for Payer: Quartz Beloit One Network |
$1,938.44
|
| Rate for Payer: Quartz Commercial |
$2,373.60
|
| Rate for Payer: WEA Trust Commercial |
$2,175.80
|
| Rate for Payer: WPS Commercial |
$2,930.21
|
|
|
BALLOON MUSTANG 5 x 40x 40CM
|
Facility
|
OP
|
$3,956.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
3467506
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,107.68 |
| Max. Negotiated Rate |
$15,824.00 |
| Rate for Payer: Aetna Commercial |
$3,560.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,402.16
|
| Rate for Payer: Aetna Managed Medicare |
$1,107.68
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,571.40
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,978.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,898.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,096.68
|
| Rate for Payer: Cash Price |
$1,186.80
|
| Rate for Payer: Cigna Commercial |
$3,639.52
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,213.78
|
| Rate for Payer: Health EOS Commercial |
$3,520.84
|
| Rate for Payer: HFN Commercial |
$3,639.52
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,967.00
|
| Rate for Payer: Multiplan Commercial |
$3,164.80
|
| Rate for Payer: NAPHCARE Commercial |
$2,373.60
|
| Rate for Payer: Preferred Network Access Commercial |
$3,639.52
|
| Rate for Payer: Quartz Beloit One Network |
$1,938.44
|
| Rate for Payer: Quartz Commercial |
$2,571.40
|
| Rate for Payer: Quartz Medicare Advantage |
$2,373.60
|
| Rate for Payer: The Alliance Commercial |
$15,824.00
|
| Rate for Payer: WEA Trust Commercial |
$2,175.80
|
| Rate for Payer: WPS Commercial |
$2,930.21
|
|
|
BALLOON MUSTANG 5 x 80x 40CM
|
Facility
|
OP
|
$3,956.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
3467511
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,107.68 |
| Max. Negotiated Rate |
$15,824.00 |
| Rate for Payer: Aetna Commercial |
$3,560.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,402.16
|
| Rate for Payer: Aetna Managed Medicare |
$1,107.68
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,571.40
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,978.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,898.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,096.68
|
| Rate for Payer: Cash Price |
$1,186.80
|
| Rate for Payer: Cigna Commercial |
$3,639.52
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,213.78
|
| Rate for Payer: Health EOS Commercial |
$3,520.84
|
| Rate for Payer: HFN Commercial |
$3,639.52
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,967.00
|
| Rate for Payer: Multiplan Commercial |
$3,164.80
|
| Rate for Payer: NAPHCARE Commercial |
$2,373.60
|
| Rate for Payer: Preferred Network Access Commercial |
$3,639.52
|
| Rate for Payer: Quartz Beloit One Network |
$1,938.44
|
| Rate for Payer: Quartz Commercial |
$2,571.40
|
| Rate for Payer: Quartz Medicare Advantage |
$2,373.60
|
| Rate for Payer: The Alliance Commercial |
$15,824.00
|
| Rate for Payer: WEA Trust Commercial |
$2,175.80
|
| Rate for Payer: WPS Commercial |
$2,930.21
|
|
|
BALLOON MUSTANG 5 x 80x 40CM
|
Facility
|
IP
|
$3,956.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
3467511
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,938.44 |
| Max. Negotiated Rate |
$3,639.52 |
| Rate for Payer: Aetna Commercial |
$3,560.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,402.16
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,096.68
|
| Rate for Payer: Cash Price |
$1,186.80
|
| Rate for Payer: Cigna Commercial |
$3,639.52
|
| Rate for Payer: Health EOS Commercial |
$3,520.84
|
| Rate for Payer: HFN Commercial |
$3,639.52
|
| Rate for Payer: Multiplan Commercial |
$3,164.80
|
| Rate for Payer: NAPHCARE Commercial |
$2,373.60
|
| Rate for Payer: Preferred Network Access Commercial |
$3,639.52
|
| Rate for Payer: Quartz Beloit One Network |
$1,938.44
|
| Rate for Payer: Quartz Commercial |
$2,373.60
|
| Rate for Payer: WEA Trust Commercial |
$2,175.80
|
| Rate for Payer: WPS Commercial |
$2,930.21
|
|
|
BALLOON MUSTANG 6.0 x 40x 75cm #3917106047
|
Facility
|
IP
|
$3,842.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
2973448
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,882.58 |
| Max. Negotiated Rate |
$3,534.64 |
| Rate for Payer: Aetna Commercial |
$3,457.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,304.12
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,036.26
|
| Rate for Payer: Cash Price |
$1,152.60
|
| Rate for Payer: Cigna Commercial |
$3,534.64
|
| Rate for Payer: Health EOS Commercial |
$3,419.38
|
| Rate for Payer: HFN Commercial |
$3,534.64
|
| Rate for Payer: Multiplan Commercial |
$3,073.60
|
| Rate for Payer: NAPHCARE Commercial |
$2,305.20
|
| Rate for Payer: Preferred Network Access Commercial |
$3,534.64
|
| Rate for Payer: Quartz Beloit One Network |
$1,882.58
|
| Rate for Payer: Quartz Commercial |
$2,305.20
|
| Rate for Payer: WEA Trust Commercial |
$2,113.10
|
| Rate for Payer: WPS Commercial |
$2,845.77
|
|
|
BALLOON MUSTANG 6.0 x 40x 75cm #3917106047
|
Facility
|
OP
|
$3,842.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
2973448
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,075.76 |
| Max. Negotiated Rate |
$15,368.00 |
| Rate for Payer: Aetna Commercial |
$3,457.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,304.12
|
| Rate for Payer: Aetna Managed Medicare |
$1,075.76
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,497.30
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,921.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,844.16
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,036.26
|
| Rate for Payer: Cash Price |
$1,152.60
|
| Rate for Payer: Cigna Commercial |
$3,534.64
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,149.98
|
| Rate for Payer: Health EOS Commercial |
$3,419.38
|
| Rate for Payer: HFN Commercial |
$3,534.64
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,881.50
|
| Rate for Payer: Multiplan Commercial |
$3,073.60
|
| Rate for Payer: NAPHCARE Commercial |
$2,305.20
|
| Rate for Payer: Preferred Network Access Commercial |
$3,534.64
|
| Rate for Payer: Quartz Beloit One Network |
$1,882.58
|
| Rate for Payer: Quartz Commercial |
$2,497.30
|
| Rate for Payer: Quartz Medicare Advantage |
$2,305.20
|
| Rate for Payer: The Alliance Commercial |
$15,368.00
|
| Rate for Payer: WEA Trust Commercial |
$2,113.10
|
| Rate for Payer: WPS Commercial |
$2,845.77
|
|
|
BALLOON MUSTANG 6 x 40x 40CM
|
Facility
|
IP
|
$3,956.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
3467507
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,938.44 |
| Max. Negotiated Rate |
$3,639.52 |
| Rate for Payer: Aetna Commercial |
$3,560.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,402.16
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,096.68
|
| Rate for Payer: Cash Price |
$1,186.80
|
| Rate for Payer: Cigna Commercial |
$3,639.52
|
| Rate for Payer: Health EOS Commercial |
$3,520.84
|
| Rate for Payer: HFN Commercial |
$3,639.52
|
| Rate for Payer: Multiplan Commercial |
$3,164.80
|
| Rate for Payer: NAPHCARE Commercial |
$2,373.60
|
| Rate for Payer: Preferred Network Access Commercial |
$3,639.52
|
| Rate for Payer: Quartz Beloit One Network |
$1,938.44
|
| Rate for Payer: Quartz Commercial |
$2,373.60
|
| Rate for Payer: WEA Trust Commercial |
$2,175.80
|
| Rate for Payer: WPS Commercial |
$2,930.21
|
|
|
BALLOON MUSTANG 6 x 40x 40CM
|
Facility
|
OP
|
$3,956.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
3467507
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,107.68 |
| Max. Negotiated Rate |
$15,824.00 |
| Rate for Payer: Aetna Commercial |
$3,560.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,402.16
|
| Rate for Payer: Aetna Managed Medicare |
$1,107.68
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,571.40
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,978.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,898.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,096.68
|
| Rate for Payer: Cash Price |
$1,186.80
|
| Rate for Payer: Cigna Commercial |
$3,639.52
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,213.78
|
| Rate for Payer: Health EOS Commercial |
$3,520.84
|
| Rate for Payer: HFN Commercial |
$3,639.52
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,967.00
|
| Rate for Payer: Multiplan Commercial |
$3,164.80
|
| Rate for Payer: NAPHCARE Commercial |
$2,373.60
|
| Rate for Payer: Preferred Network Access Commercial |
$3,639.52
|
| Rate for Payer: Quartz Beloit One Network |
$1,938.44
|
| Rate for Payer: Quartz Commercial |
$2,571.40
|
| Rate for Payer: Quartz Medicare Advantage |
$2,373.60
|
| Rate for Payer: The Alliance Commercial |
$15,824.00
|
| Rate for Payer: WEA Trust Commercial |
$2,175.80
|
| Rate for Payer: WPS Commercial |
$2,930.21
|
|
|
BALLOON MUSTANG 6 x 80x 40CM
|
Facility
|
OP
|
$3,956.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
3467512
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,107.68 |
| Max. Negotiated Rate |
$15,824.00 |
| Rate for Payer: Aetna Commercial |
$3,560.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,402.16
|
| Rate for Payer: Aetna Managed Medicare |
$1,107.68
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,571.40
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,978.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,898.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,096.68
|
| Rate for Payer: Cash Price |
$1,186.80
|
| Rate for Payer: Cigna Commercial |
$3,639.52
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,213.78
|
| Rate for Payer: Health EOS Commercial |
$3,520.84
|
| Rate for Payer: HFN Commercial |
$3,639.52
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,967.00
|
| Rate for Payer: Multiplan Commercial |
$3,164.80
|
| Rate for Payer: NAPHCARE Commercial |
$2,373.60
|
| Rate for Payer: Preferred Network Access Commercial |
$3,639.52
|
| Rate for Payer: Quartz Beloit One Network |
$1,938.44
|
| Rate for Payer: Quartz Commercial |
$2,571.40
|
| Rate for Payer: Quartz Medicare Advantage |
$2,373.60
|
| Rate for Payer: The Alliance Commercial |
$15,824.00
|
| Rate for Payer: WEA Trust Commercial |
$2,175.80
|
| Rate for Payer: WPS Commercial |
$2,930.21
|
|
|
BALLOON MUSTANG 6 x 80x 40CM
|
Facility
|
IP
|
$3,956.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
3467512
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,938.44 |
| Max. Negotiated Rate |
$3,639.52 |
| Rate for Payer: Aetna Commercial |
$3,560.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,402.16
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,096.68
|
| Rate for Payer: Cash Price |
$1,186.80
|
| Rate for Payer: Cigna Commercial |
$3,639.52
|
| Rate for Payer: Health EOS Commercial |
$3,520.84
|
| Rate for Payer: HFN Commercial |
$3,639.52
|
| Rate for Payer: Multiplan Commercial |
$3,164.80
|
| Rate for Payer: NAPHCARE Commercial |
$2,373.60
|
| Rate for Payer: Preferred Network Access Commercial |
$3,639.52
|
| Rate for Payer: Quartz Beloit One Network |
$1,938.44
|
| Rate for Payer: Quartz Commercial |
$2,373.60
|
| Rate for Payer: WEA Trust Commercial |
$2,175.80
|
| Rate for Payer: WPS Commercial |
$2,930.21
|
|
|
BALLOON MUSTANG 7.0 x 40x 75cm #3917107047
|
Facility
|
OP
|
$3,842.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
2973449
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,075.76 |
| Max. Negotiated Rate |
$15,368.00 |
| Rate for Payer: Aetna Commercial |
$3,457.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,304.12
|
| Rate for Payer: Aetna Managed Medicare |
$1,075.76
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,497.30
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,921.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,844.16
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,036.26
|
| Rate for Payer: Cash Price |
$1,152.60
|
| Rate for Payer: Cigna Commercial |
$3,534.64
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,149.98
|
| Rate for Payer: Health EOS Commercial |
$3,419.38
|
| Rate for Payer: HFN Commercial |
$3,534.64
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,881.50
|
| Rate for Payer: Multiplan Commercial |
$3,073.60
|
| Rate for Payer: NAPHCARE Commercial |
$2,305.20
|
| Rate for Payer: Preferred Network Access Commercial |
$3,534.64
|
| Rate for Payer: Quartz Beloit One Network |
$1,882.58
|
| Rate for Payer: Quartz Commercial |
$2,497.30
|
| Rate for Payer: Quartz Medicare Advantage |
$2,305.20
|
| Rate for Payer: The Alliance Commercial |
$15,368.00
|
| Rate for Payer: WEA Trust Commercial |
$2,113.10
|
| Rate for Payer: WPS Commercial |
$2,845.77
|
|
|
BALLOON MUSTANG 7.0 x 40x 75cm #3917107047
|
Facility
|
IP
|
$3,842.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
2973449
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,882.58 |
| Max. Negotiated Rate |
$3,534.64 |
| Rate for Payer: Aetna Commercial |
$3,457.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,304.12
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,036.26
|
| Rate for Payer: Cash Price |
$1,152.60
|
| Rate for Payer: Cigna Commercial |
$3,534.64
|
| Rate for Payer: Health EOS Commercial |
$3,419.38
|
| Rate for Payer: HFN Commercial |
$3,534.64
|
| Rate for Payer: Multiplan Commercial |
$3,073.60
|
| Rate for Payer: NAPHCARE Commercial |
$2,305.20
|
| Rate for Payer: Preferred Network Access Commercial |
$3,534.64
|
| Rate for Payer: Quartz Beloit One Network |
$1,882.58
|
| Rate for Payer: Quartz Commercial |
$2,305.20
|
| Rate for Payer: WEA Trust Commercial |
$2,113.10
|
| Rate for Payer: WPS Commercial |
$2,845.77
|
|
|
BALLOON MUSTANG 7 x 40x 40CM 39171-07044
|
Facility
|
OP
|
$3,956.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
3467508
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,107.68 |
| Max. Negotiated Rate |
$15,824.00 |
| Rate for Payer: Aetna Commercial |
$3,560.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,402.16
|
| Rate for Payer: Aetna Managed Medicare |
$1,107.68
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,571.40
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,978.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,898.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,096.68
|
| Rate for Payer: Cash Price |
$1,186.80
|
| Rate for Payer: Cigna Commercial |
$3,639.52
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,213.78
|
| Rate for Payer: Health EOS Commercial |
$3,520.84
|
| Rate for Payer: HFN Commercial |
$3,639.52
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,967.00
|
| Rate for Payer: Multiplan Commercial |
$3,164.80
|
| Rate for Payer: NAPHCARE Commercial |
$2,373.60
|
| Rate for Payer: Preferred Network Access Commercial |
$3,639.52
|
| Rate for Payer: Quartz Beloit One Network |
$1,938.44
|
| Rate for Payer: Quartz Commercial |
$2,571.40
|
| Rate for Payer: Quartz Medicare Advantage |
$2,373.60
|
| Rate for Payer: The Alliance Commercial |
$15,824.00
|
| Rate for Payer: WEA Trust Commercial |
$2,175.80
|
| Rate for Payer: WPS Commercial |
$2,930.21
|
|
|
BALLOON MUSTANG 7 x 40x 40CM 39171-07044
|
Facility
|
IP
|
$3,956.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
3467508
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,938.44 |
| Max. Negotiated Rate |
$3,639.52 |
| Rate for Payer: Aetna Commercial |
$3,560.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,402.16
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,096.68
|
| Rate for Payer: Cash Price |
$1,186.80
|
| Rate for Payer: Cigna Commercial |
$3,639.52
|
| Rate for Payer: Health EOS Commercial |
$3,520.84
|
| Rate for Payer: HFN Commercial |
$3,639.52
|
| Rate for Payer: Multiplan Commercial |
$3,164.80
|
| Rate for Payer: NAPHCARE Commercial |
$2,373.60
|
| Rate for Payer: Preferred Network Access Commercial |
$3,639.52
|
| Rate for Payer: Quartz Beloit One Network |
$1,938.44
|
| Rate for Payer: Quartz Commercial |
$2,373.60
|
| Rate for Payer: WEA Trust Commercial |
$2,175.80
|
| Rate for Payer: WPS Commercial |
$2,930.21
|
|
|
BALLOON MUSTANG 7 x 80x 40CM
|
Facility
|
IP
|
$3,956.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
3467513
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,938.44 |
| Max. Negotiated Rate |
$3,639.52 |
| Rate for Payer: Aetna Commercial |
$3,560.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,402.16
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,096.68
|
| Rate for Payer: Cash Price |
$1,186.80
|
| Rate for Payer: Cigna Commercial |
$3,639.52
|
| Rate for Payer: Health EOS Commercial |
$3,520.84
|
| Rate for Payer: HFN Commercial |
$3,639.52
|
| Rate for Payer: Multiplan Commercial |
$3,164.80
|
| Rate for Payer: NAPHCARE Commercial |
$2,373.60
|
| Rate for Payer: Preferred Network Access Commercial |
$3,639.52
|
| Rate for Payer: Quartz Beloit One Network |
$1,938.44
|
| Rate for Payer: Quartz Commercial |
$2,373.60
|
| Rate for Payer: WEA Trust Commercial |
$2,175.80
|
| Rate for Payer: WPS Commercial |
$2,930.21
|
|
|
BALLOON MUSTANG 7 x 80x 40CM
|
Facility
|
OP
|
$3,956.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
3467513
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,107.68 |
| Max. Negotiated Rate |
$15,824.00 |
| Rate for Payer: Aetna Commercial |
$3,560.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,402.16
|
| Rate for Payer: Aetna Managed Medicare |
$1,107.68
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,571.40
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,978.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,898.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,096.68
|
| Rate for Payer: Cash Price |
$1,186.80
|
| Rate for Payer: Cigna Commercial |
$3,639.52
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,213.78
|
| Rate for Payer: Health EOS Commercial |
$3,520.84
|
| Rate for Payer: HFN Commercial |
$3,639.52
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,967.00
|
| Rate for Payer: Multiplan Commercial |
$3,164.80
|
| Rate for Payer: NAPHCARE Commercial |
$2,373.60
|
| Rate for Payer: Preferred Network Access Commercial |
$3,639.52
|
| Rate for Payer: Quartz Beloit One Network |
$1,938.44
|
| Rate for Payer: Quartz Commercial |
$2,571.40
|
| Rate for Payer: Quartz Medicare Advantage |
$2,373.60
|
| Rate for Payer: The Alliance Commercial |
$15,824.00
|
| Rate for Payer: WEA Trust Commercial |
$2,175.80
|
| Rate for Payer: WPS Commercial |
$2,930.21
|
|
|
BALLOON MUSTANG 8.0 x 40x 75cm #3917108047
|
Facility
|
OP
|
$3,842.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
2973450
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,075.76 |
| Max. Negotiated Rate |
$15,368.00 |
| Rate for Payer: Aetna Commercial |
$3,457.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,304.12
|
| Rate for Payer: Aetna Managed Medicare |
$1,075.76
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,497.30
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,921.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,844.16
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,036.26
|
| Rate for Payer: Cash Price |
$1,152.60
|
| Rate for Payer: Cigna Commercial |
$3,534.64
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,149.98
|
| Rate for Payer: Health EOS Commercial |
$3,419.38
|
| Rate for Payer: HFN Commercial |
$3,534.64
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,881.50
|
| Rate for Payer: Multiplan Commercial |
$3,073.60
|
| Rate for Payer: NAPHCARE Commercial |
$2,305.20
|
| Rate for Payer: Preferred Network Access Commercial |
$3,534.64
|
| Rate for Payer: Quartz Beloit One Network |
$1,882.58
|
| Rate for Payer: Quartz Commercial |
$2,497.30
|
| Rate for Payer: Quartz Medicare Advantage |
$2,305.20
|
| Rate for Payer: The Alliance Commercial |
$15,368.00
|
| Rate for Payer: WEA Trust Commercial |
$2,113.10
|
| Rate for Payer: WPS Commercial |
$2,845.77
|
|
|
BALLOON MUSTANG 8.0 x 40x 75cm #3917108047
|
Facility
|
IP
|
$3,842.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
2973450
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,882.58 |
| Max. Negotiated Rate |
$3,534.64 |
| Rate for Payer: Aetna Commercial |
$3,457.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,304.12
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,036.26
|
| Rate for Payer: Cash Price |
$1,152.60
|
| Rate for Payer: Cigna Commercial |
$3,534.64
|
| Rate for Payer: Health EOS Commercial |
$3,419.38
|
| Rate for Payer: HFN Commercial |
$3,534.64
|
| Rate for Payer: Multiplan Commercial |
$3,073.60
|
| Rate for Payer: NAPHCARE Commercial |
$2,305.20
|
| Rate for Payer: Preferred Network Access Commercial |
$3,534.64
|
| Rate for Payer: Quartz Beloit One Network |
$1,882.58
|
| Rate for Payer: Quartz Commercial |
$2,305.20
|
| Rate for Payer: WEA Trust Commercial |
$2,113.10
|
| Rate for Payer: WPS Commercial |
$2,845.77
|
|
|
BALLOON MUSTANG 8 x 40x 40CM H74939171080440
|
Facility
|
OP
|
$3,956.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
3467509
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,107.68 |
| Max. Negotiated Rate |
$15,824.00 |
| Rate for Payer: Aetna Commercial |
$3,560.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,402.16
|
| Rate for Payer: Aetna Managed Medicare |
$1,107.68
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,571.40
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,978.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,898.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,096.68
|
| Rate for Payer: Cash Price |
$1,186.80
|
| Rate for Payer: Cigna Commercial |
$3,639.52
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,213.78
|
| Rate for Payer: Health EOS Commercial |
$3,520.84
|
| Rate for Payer: HFN Commercial |
$3,639.52
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,967.00
|
| Rate for Payer: Multiplan Commercial |
$3,164.80
|
| Rate for Payer: NAPHCARE Commercial |
$2,373.60
|
| Rate for Payer: Preferred Network Access Commercial |
$3,639.52
|
| Rate for Payer: Quartz Beloit One Network |
$1,938.44
|
| Rate for Payer: Quartz Commercial |
$2,571.40
|
| Rate for Payer: Quartz Medicare Advantage |
$2,373.60
|
| Rate for Payer: The Alliance Commercial |
$15,824.00
|
| Rate for Payer: WEA Trust Commercial |
$2,175.80
|
| Rate for Payer: WPS Commercial |
$2,930.21
|
|
|
BALLOON MUSTANG 8 x 40x 40CM H74939171080440
|
Facility
|
IP
|
$3,956.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
3467509
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,938.44 |
| Max. Negotiated Rate |
$3,639.52 |
| Rate for Payer: Aetna Commercial |
$3,560.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,402.16
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,096.68
|
| Rate for Payer: Cash Price |
$1,186.80
|
| Rate for Payer: Cigna Commercial |
$3,639.52
|
| Rate for Payer: Health EOS Commercial |
$3,520.84
|
| Rate for Payer: HFN Commercial |
$3,639.52
|
| Rate for Payer: Multiplan Commercial |
$3,164.80
|
| Rate for Payer: NAPHCARE Commercial |
$2,373.60
|
| Rate for Payer: Preferred Network Access Commercial |
$3,639.52
|
| Rate for Payer: Quartz Beloit One Network |
$1,938.44
|
| Rate for Payer: Quartz Commercial |
$2,373.60
|
| Rate for Payer: WEA Trust Commercial |
$2,175.80
|
| Rate for Payer: WPS Commercial |
$2,930.21
|
|
|
BALLOON MUSTANG 8 x 80x 40CM
|
Facility
|
OP
|
$3,956.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
3467514
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,107.68 |
| Max. Negotiated Rate |
$15,824.00 |
| Rate for Payer: Aetna Commercial |
$3,560.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,402.16
|
| Rate for Payer: Aetna Managed Medicare |
$1,107.68
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,571.40
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,978.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,898.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,096.68
|
| Rate for Payer: Cash Price |
$1,186.80
|
| Rate for Payer: Cigna Commercial |
$3,639.52
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,213.78
|
| Rate for Payer: Health EOS Commercial |
$3,520.84
|
| Rate for Payer: HFN Commercial |
$3,639.52
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,967.00
|
| Rate for Payer: Multiplan Commercial |
$3,164.80
|
| Rate for Payer: NAPHCARE Commercial |
$2,373.60
|
| Rate for Payer: Preferred Network Access Commercial |
$3,639.52
|
| Rate for Payer: Quartz Beloit One Network |
$1,938.44
|
| Rate for Payer: Quartz Commercial |
$2,571.40
|
| Rate for Payer: Quartz Medicare Advantage |
$2,373.60
|
| Rate for Payer: The Alliance Commercial |
$15,824.00
|
| Rate for Payer: WEA Trust Commercial |
$2,175.80
|
| Rate for Payer: WPS Commercial |
$2,930.21
|
|
|
BALLOON MUSTANG 8 x 80x 40CM
|
Facility
|
IP
|
$3,956.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
3467514
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,938.44 |
| Max. Negotiated Rate |
$3,639.52 |
| Rate for Payer: Aetna Commercial |
$3,560.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,402.16
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,096.68
|
| Rate for Payer: Cash Price |
$1,186.80
|
| Rate for Payer: Cigna Commercial |
$3,639.52
|
| Rate for Payer: Health EOS Commercial |
$3,520.84
|
| Rate for Payer: HFN Commercial |
$3,639.52
|
| Rate for Payer: Multiplan Commercial |
$3,164.80
|
| Rate for Payer: NAPHCARE Commercial |
$2,373.60
|
| Rate for Payer: Preferred Network Access Commercial |
$3,639.52
|
| Rate for Payer: Quartz Beloit One Network |
$1,938.44
|
| Rate for Payer: Quartz Commercial |
$2,373.60
|
| Rate for Payer: WEA Trust Commercial |
$2,175.80
|
| Rate for Payer: WPS Commercial |
$2,930.21
|
|
|
BALLOON NANOCROSS 2.0x120x150
|
Facility
|
IP
|
$3,294.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
2973350
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,614.06 |
| Max. Negotiated Rate |
$3,030.48 |
| Rate for Payer: Aetna Commercial |
$2,964.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,832.84
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,745.82
|
| Rate for Payer: Cash Price |
$988.20
|
| Rate for Payer: Cigna Commercial |
$3,030.48
|
| Rate for Payer: Health EOS Commercial |
$2,931.66
|
| Rate for Payer: HFN Commercial |
$3,030.48
|
| Rate for Payer: Multiplan Commercial |
$2,635.20
|
| Rate for Payer: NAPHCARE Commercial |
$1,976.40
|
| Rate for Payer: Preferred Network Access Commercial |
$3,030.48
|
| Rate for Payer: Quartz Beloit One Network |
$1,614.06
|
| Rate for Payer: Quartz Commercial |
$1,976.40
|
| Rate for Payer: WEA Trust Commercial |
$1,811.70
|
| Rate for Payer: WPS Commercial |
$2,439.87
|
|
|
BALLOON NANOCROSS 2.0x120x150
|
Facility
|
OP
|
$3,294.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
2973350
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$922.32 |
| Max. Negotiated Rate |
$13,176.00 |
| Rate for Payer: Aetna Commercial |
$2,964.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,832.84
|
| Rate for Payer: Aetna Managed Medicare |
$922.32
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,141.10
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,647.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,581.12
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,745.82
|
| Rate for Payer: Cash Price |
$988.20
|
| Rate for Payer: Cigna Commercial |
$3,030.48
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,843.32
|
| Rate for Payer: Health EOS Commercial |
$2,931.66
|
| Rate for Payer: HFN Commercial |
$3,030.48
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,470.50
|
| Rate for Payer: Multiplan Commercial |
$2,635.20
|
| Rate for Payer: NAPHCARE Commercial |
$1,976.40
|
| Rate for Payer: Preferred Network Access Commercial |
$3,030.48
|
| Rate for Payer: Quartz Beloit One Network |
$1,614.06
|
| Rate for Payer: Quartz Commercial |
$2,141.10
|
| Rate for Payer: Quartz Medicare Advantage |
$1,976.40
|
| Rate for Payer: The Alliance Commercial |
$13,176.00
|
| Rate for Payer: WEA Trust Commercial |
$1,811.70
|
| Rate for Payer: WPS Commercial |
$2,439.87
|
|
