|
BALLOON NANOCROSS 2.0 x 150mm #AB14W020150150
|
Facility
|
OP
|
$4,452.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
2973517
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,246.56 |
| Max. Negotiated Rate |
$17,808.00 |
| Rate for Payer: Aetna Commercial |
$4,006.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,828.72
|
| Rate for Payer: Aetna Managed Medicare |
$1,246.56
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,893.80
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,226.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,136.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,359.56
|
| Rate for Payer: Cash Price |
$1,335.60
|
| Rate for Payer: Cigna Commercial |
$4,095.84
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,491.34
|
| Rate for Payer: Health EOS Commercial |
$3,962.28
|
| Rate for Payer: HFN Commercial |
$4,095.84
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,339.00
|
| Rate for Payer: Multiplan Commercial |
$3,561.60
|
| Rate for Payer: NAPHCARE Commercial |
$2,671.20
|
| Rate for Payer: Preferred Network Access Commercial |
$4,095.84
|
| Rate for Payer: Quartz Beloit One Network |
$2,181.48
|
| Rate for Payer: Quartz Commercial |
$2,893.80
|
| Rate for Payer: Quartz Medicare Advantage |
$2,671.20
|
| Rate for Payer: The Alliance Commercial |
$17,808.00
|
| Rate for Payer: WEA Trust Commercial |
$2,448.60
|
| Rate for Payer: WPS Commercial |
$3,297.60
|
|
|
BALLOON NANOCROSS 2.0 x 150mm #AB14W020150150
|
Facility
|
IP
|
$4,452.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
2973517
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$2,181.48 |
| Max. Negotiated Rate |
$4,095.84 |
| Rate for Payer: Aetna Commercial |
$4,006.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,828.72
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,359.56
|
| Rate for Payer: Cash Price |
$1,335.60
|
| Rate for Payer: Cigna Commercial |
$4,095.84
|
| Rate for Payer: Health EOS Commercial |
$3,962.28
|
| Rate for Payer: HFN Commercial |
$4,095.84
|
| Rate for Payer: Multiplan Commercial |
$3,561.60
|
| Rate for Payer: NAPHCARE Commercial |
$2,671.20
|
| Rate for Payer: Preferred Network Access Commercial |
$4,095.84
|
| Rate for Payer: Quartz Beloit One Network |
$2,181.48
|
| Rate for Payer: Quartz Commercial |
$2,671.20
|
| Rate for Payer: WEA Trust Commercial |
$2,448.60
|
| Rate for Payer: WPS Commercial |
$3,297.60
|
|
|
BALLOON NANOCROSS 2.0 x 40mm X 150
|
Facility
|
OP
|
$3,414.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
2973380
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$955.92 |
| Max. Negotiated Rate |
$13,656.00 |
| Rate for Payer: Aetna Commercial |
$3,072.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,936.04
|
| Rate for Payer: Aetna Managed Medicare |
$955.92
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,219.10
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,707.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,638.72
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,809.42
|
| Rate for Payer: Cash Price |
$1,024.20
|
| Rate for Payer: Cigna Commercial |
$3,140.88
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,910.47
|
| Rate for Payer: Health EOS Commercial |
$3,038.46
|
| Rate for Payer: HFN Commercial |
$3,140.88
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,560.50
|
| Rate for Payer: Multiplan Commercial |
$2,731.20
|
| Rate for Payer: NAPHCARE Commercial |
$2,048.40
|
| Rate for Payer: Preferred Network Access Commercial |
$3,140.88
|
| Rate for Payer: Quartz Beloit One Network |
$1,672.86
|
| Rate for Payer: Quartz Commercial |
$2,219.10
|
| Rate for Payer: Quartz Medicare Advantage |
$2,048.40
|
| Rate for Payer: The Alliance Commercial |
$13,656.00
|
| Rate for Payer: WEA Trust Commercial |
$1,877.70
|
| Rate for Payer: WPS Commercial |
$2,528.75
|
|
|
BALLOON NANOCROSS 2.0 x 40mm X 150
|
Facility
|
IP
|
$3,414.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
2973380
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,672.86 |
| Max. Negotiated Rate |
$3,140.88 |
| Rate for Payer: Aetna Commercial |
$3,072.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,936.04
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,809.42
|
| Rate for Payer: Cash Price |
$1,024.20
|
| Rate for Payer: Cigna Commercial |
$3,140.88
|
| Rate for Payer: Health EOS Commercial |
$3,038.46
|
| Rate for Payer: HFN Commercial |
$3,140.88
|
| Rate for Payer: Multiplan Commercial |
$2,731.20
|
| Rate for Payer: NAPHCARE Commercial |
$2,048.40
|
| Rate for Payer: Preferred Network Access Commercial |
$3,140.88
|
| Rate for Payer: Quartz Beloit One Network |
$1,672.86
|
| Rate for Payer: Quartz Commercial |
$2,048.40
|
| Rate for Payer: WEA Trust Commercial |
$1,877.70
|
| Rate for Payer: WPS Commercial |
$2,528.75
|
|
|
BALLOON NANOCROSS 2.0 x 80mm
|
Facility
|
OP
|
$3,294.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
2973351
|
|
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
|
|
|
BALLOON NANOCROSS 2.0 x 80mm
|
Facility
|
IP
|
$3,294.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
2973351
|
|
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 2.5x120x150
|
Facility
|
IP
|
$3,294.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
2973379
|
|
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 2.5x120x150
|
Facility
|
OP
|
$3,294.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
2973379
|
|
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
|
|
|
BALLOON NANOCROSS 2.5 x 150mm
|
Facility
|
OP
|
$3,538.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
2973400
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$990.64 |
| Max. Negotiated Rate |
$14,152.00 |
| Rate for Payer: Aetna Commercial |
$3,184.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,042.68
|
| Rate for Payer: Aetna Managed Medicare |
$990.64
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,299.70
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,769.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,698.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,875.14
|
| Rate for Payer: Cash Price |
$1,061.40
|
| Rate for Payer: Cigna Commercial |
$3,254.96
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,979.86
|
| Rate for Payer: Health EOS Commercial |
$3,148.82
|
| Rate for Payer: HFN Commercial |
$3,254.96
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,653.50
|
| Rate for Payer: Multiplan Commercial |
$2,830.40
|
| Rate for Payer: NAPHCARE Commercial |
$2,122.80
|
| Rate for Payer: Preferred Network Access Commercial |
$3,254.96
|
| Rate for Payer: Quartz Beloit One Network |
$1,733.62
|
| Rate for Payer: Quartz Commercial |
$2,299.70
|
| Rate for Payer: Quartz Medicare Advantage |
$2,122.80
|
| Rate for Payer: The Alliance Commercial |
$14,152.00
|
| Rate for Payer: WEA Trust Commercial |
$1,945.90
|
| Rate for Payer: WPS Commercial |
$2,620.60
|
|
|
BALLOON NANOCROSS 2.5 x 150mm
|
Facility
|
IP
|
$3,538.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
2973400
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,733.62 |
| Max. Negotiated Rate |
$3,254.96 |
| Rate for Payer: Aetna Commercial |
$3,184.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,042.68
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,875.14
|
| Rate for Payer: Cash Price |
$1,061.40
|
| Rate for Payer: Cigna Commercial |
$3,254.96
|
| Rate for Payer: Health EOS Commercial |
$3,148.82
|
| Rate for Payer: HFN Commercial |
$3,254.96
|
| Rate for Payer: Multiplan Commercial |
$2,830.40
|
| Rate for Payer: NAPHCARE Commercial |
$2,122.80
|
| Rate for Payer: Preferred Network Access Commercial |
$3,254.96
|
| Rate for Payer: Quartz Beloit One Network |
$1,733.62
|
| Rate for Payer: Quartz Commercial |
$2,122.80
|
| Rate for Payer: WEA Trust Commercial |
$1,945.90
|
| Rate for Payer: WPS Commercial |
$2,620.60
|
|
|
BALLOON NANOCROSS 2.5 x 40mm
|
Facility
|
IP
|
$3,414.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
2973381
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,672.86 |
| Max. Negotiated Rate |
$3,140.88 |
| Rate for Payer: Aetna Commercial |
$3,072.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,936.04
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,809.42
|
| Rate for Payer: Cash Price |
$1,024.20
|
| Rate for Payer: Cigna Commercial |
$3,140.88
|
| Rate for Payer: Health EOS Commercial |
$3,038.46
|
| Rate for Payer: HFN Commercial |
$3,140.88
|
| Rate for Payer: Multiplan Commercial |
$2,731.20
|
| Rate for Payer: NAPHCARE Commercial |
$2,048.40
|
| Rate for Payer: Preferred Network Access Commercial |
$3,140.88
|
| Rate for Payer: Quartz Beloit One Network |
$1,672.86
|
| Rate for Payer: Quartz Commercial |
$2,048.40
|
| Rate for Payer: WEA Trust Commercial |
$1,877.70
|
| Rate for Payer: WPS Commercial |
$2,528.75
|
|
|
BALLOON NANOCROSS 2.5 x 40mm
|
Facility
|
OP
|
$3,414.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
2973381
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$955.92 |
| Max. Negotiated Rate |
$13,656.00 |
| Rate for Payer: Aetna Commercial |
$3,072.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,936.04
|
| Rate for Payer: Aetna Managed Medicare |
$955.92
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,219.10
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,707.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,638.72
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,809.42
|
| Rate for Payer: Cash Price |
$1,024.20
|
| Rate for Payer: Cigna Commercial |
$3,140.88
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,910.47
|
| Rate for Payer: Health EOS Commercial |
$3,038.46
|
| Rate for Payer: HFN Commercial |
$3,140.88
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,560.50
|
| Rate for Payer: Multiplan Commercial |
$2,731.20
|
| Rate for Payer: NAPHCARE Commercial |
$2,048.40
|
| Rate for Payer: Preferred Network Access Commercial |
$3,140.88
|
| Rate for Payer: Quartz Beloit One Network |
$1,672.86
|
| Rate for Payer: Quartz Commercial |
$2,219.10
|
| Rate for Payer: Quartz Medicare Advantage |
$2,048.40
|
| Rate for Payer: The Alliance Commercial |
$13,656.00
|
| Rate for Payer: WEA Trust Commercial |
$1,877.70
|
| Rate for Payer: WPS Commercial |
$2,528.75
|
|
|
BALLOON NANOCROSS 2.5x80x150
|
Facility
|
IP
|
$3,414.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
2973378
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,672.86 |
| Max. Negotiated Rate |
$3,140.88 |
| Rate for Payer: Aetna Commercial |
$3,072.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,936.04
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,809.42
|
| Rate for Payer: Cash Price |
$1,024.20
|
| Rate for Payer: Cigna Commercial |
$3,140.88
|
| Rate for Payer: Health EOS Commercial |
$3,038.46
|
| Rate for Payer: HFN Commercial |
$3,140.88
|
| Rate for Payer: Multiplan Commercial |
$2,731.20
|
| Rate for Payer: NAPHCARE Commercial |
$2,048.40
|
| Rate for Payer: Preferred Network Access Commercial |
$3,140.88
|
| Rate for Payer: Quartz Beloit One Network |
$1,672.86
|
| Rate for Payer: Quartz Commercial |
$2,048.40
|
| Rate for Payer: WEA Trust Commercial |
$1,877.70
|
| Rate for Payer: WPS Commercial |
$2,528.75
|
|
|
BALLOON NANOCROSS 2.5x80x150
|
Facility
|
OP
|
$3,414.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
2973378
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$955.92 |
| Max. Negotiated Rate |
$13,656.00 |
| Rate for Payer: Aetna Commercial |
$3,072.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,936.04
|
| Rate for Payer: Aetna Managed Medicare |
$955.92
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,219.10
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,707.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,638.72
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,809.42
|
| Rate for Payer: Cash Price |
$1,024.20
|
| Rate for Payer: Cigna Commercial |
$3,140.88
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,910.47
|
| Rate for Payer: Health EOS Commercial |
$3,038.46
|
| Rate for Payer: HFN Commercial |
$3,140.88
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,560.50
|
| Rate for Payer: Multiplan Commercial |
$2,731.20
|
| Rate for Payer: NAPHCARE Commercial |
$2,048.40
|
| Rate for Payer: Preferred Network Access Commercial |
$3,140.88
|
| Rate for Payer: Quartz Beloit One Network |
$1,672.86
|
| Rate for Payer: Quartz Commercial |
$2,219.10
|
| Rate for Payer: Quartz Medicare Advantage |
$2,048.40
|
| Rate for Payer: The Alliance Commercial |
$13,656.00
|
| Rate for Payer: WEA Trust Commercial |
$1,877.70
|
| Rate for Payer: WPS Commercial |
$2,528.75
|
|
|
BALLOON NANOCROSS 3.0X40mmX150
|
Facility
|
OP
|
$3,294.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
2973382
|
|
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
|
|
|
BALLOON NANOCROSS 3.0X40mmX150
|
Facility
|
IP
|
$3,294.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
2973382
|
|
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 3.0X80mmX150
|
Facility
|
OP
|
$3,294.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
2973352
|
|
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
|
|
|
BALLOON NANOCROSS 3.0X80mmX150
|
Facility
|
IP
|
$3,294.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
2973352
|
|
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 3 X120mmX150
|
Facility
|
OP
|
$3,294.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
2973353
|
|
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
|
|
|
BALLOON NANOCROSS 3 X120mmX150
|
Facility
|
IP
|
$3,294.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
2973353
|
|
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 NC TREK 2.0 X 12MM 1012445-12
|
Facility
|
IP
|
$3,657.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
3645498
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,791.93 |
| Max. Negotiated Rate |
$3,364.44 |
| Rate for Payer: Aetna Commercial |
$3,291.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,145.02
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,938.21
|
| Rate for Payer: Cash Price |
$1,097.10
|
| Rate for Payer: Cigna Commercial |
$3,364.44
|
| Rate for Payer: Health EOS Commercial |
$3,254.73
|
| Rate for Payer: HFN Commercial |
$3,364.44
|
| Rate for Payer: Multiplan Commercial |
$2,925.60
|
| Rate for Payer: NAPHCARE Commercial |
$2,194.20
|
| Rate for Payer: Preferred Network Access Commercial |
$3,364.44
|
| Rate for Payer: Quartz Beloit One Network |
$1,791.93
|
| Rate for Payer: Quartz Commercial |
$2,194.20
|
| Rate for Payer: WEA Trust Commercial |
$2,011.35
|
| Rate for Payer: WPS Commercial |
$2,708.74
|
|
|
BALLOON NC TREK 2.0 X 12MM 1012445-12
|
Facility
|
OP
|
$3,657.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
3645498
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,023.96 |
| Max. Negotiated Rate |
$14,628.00 |
| Rate for Payer: Aetna Commercial |
$3,291.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,145.02
|
| Rate for Payer: Aetna Managed Medicare |
$1,023.96
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,377.05
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,828.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,755.36
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,938.21
|
| Rate for Payer: Cash Price |
$1,097.10
|
| Rate for Payer: Cigna Commercial |
$3,364.44
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,046.46
|
| Rate for Payer: Health EOS Commercial |
$3,254.73
|
| Rate for Payer: HFN Commercial |
$3,364.44
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,742.75
|
| Rate for Payer: Multiplan Commercial |
$2,925.60
|
| Rate for Payer: NAPHCARE Commercial |
$2,194.20
|
| Rate for Payer: Preferred Network Access Commercial |
$3,364.44
|
| Rate for Payer: Quartz Beloit One Network |
$1,791.93
|
| Rate for Payer: Quartz Commercial |
$2,377.05
|
| Rate for Payer: Quartz Medicare Advantage |
$2,194.20
|
| Rate for Payer: The Alliance Commercial |
$14,628.00
|
| Rate for Payer: WEA Trust Commercial |
$2,011.35
|
| Rate for Payer: WPS Commercial |
$2,708.74
|
|
|
BALLOON NC TREK 2.5 X 12
|
Facility
|
OP
|
$3,657.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
3529511
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,023.96 |
| Max. Negotiated Rate |
$14,628.00 |
| Rate for Payer: Aetna Commercial |
$3,291.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,145.02
|
| Rate for Payer: Aetna Managed Medicare |
$1,023.96
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,377.05
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,828.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,755.36
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,938.21
|
| Rate for Payer: Cash Price |
$1,097.10
|
| Rate for Payer: Cigna Commercial |
$3,364.44
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,046.46
|
| Rate for Payer: Health EOS Commercial |
$3,254.73
|
| Rate for Payer: HFN Commercial |
$3,364.44
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,742.75
|
| Rate for Payer: Multiplan Commercial |
$2,925.60
|
| Rate for Payer: NAPHCARE Commercial |
$2,194.20
|
| Rate for Payer: Preferred Network Access Commercial |
$3,364.44
|
| Rate for Payer: Quartz Beloit One Network |
$1,791.93
|
| Rate for Payer: Quartz Commercial |
$2,377.05
|
| Rate for Payer: Quartz Medicare Advantage |
$2,194.20
|
| Rate for Payer: The Alliance Commercial |
$14,628.00
|
| Rate for Payer: WEA Trust Commercial |
$2,011.35
|
| Rate for Payer: WPS Commercial |
$2,708.74
|
|
|
BALLOON NC TREK 2.5 X 12
|
Facility
|
IP
|
$3,657.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
3529511
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,791.93 |
| Max. Negotiated Rate |
$3,364.44 |
| Rate for Payer: Aetna Commercial |
$3,291.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,145.02
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,938.21
|
| Rate for Payer: Cash Price |
$1,097.10
|
| Rate for Payer: Cigna Commercial |
$3,364.44
|
| Rate for Payer: Health EOS Commercial |
$3,254.73
|
| Rate for Payer: HFN Commercial |
$3,364.44
|
| Rate for Payer: Multiplan Commercial |
$2,925.60
|
| Rate for Payer: NAPHCARE Commercial |
$2,194.20
|
| Rate for Payer: Preferred Network Access Commercial |
$3,364.44
|
| Rate for Payer: Quartz Beloit One Network |
$1,791.93
|
| Rate for Payer: Quartz Commercial |
$2,194.20
|
| Rate for Payer: WEA Trust Commercial |
$2,011.35
|
| Rate for Payer: WPS Commercial |
$2,708.74
|
|
|
BALLOON NC TREK 2.5x8mm #1012447-08
|
Facility
|
OP
|
$3,657.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
2973241
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,023.96 |
| Max. Negotiated Rate |
$14,628.00 |
| Rate for Payer: Aetna Commercial |
$3,291.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,145.02
|
| Rate for Payer: Aetna Managed Medicare |
$1,023.96
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,377.05
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,828.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,755.36
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,938.21
|
| Rate for Payer: Cash Price |
$1,097.10
|
| Rate for Payer: Cigna Commercial |
$3,364.44
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,046.46
|
| Rate for Payer: Health EOS Commercial |
$3,254.73
|
| Rate for Payer: HFN Commercial |
$3,364.44
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,742.75
|
| Rate for Payer: Multiplan Commercial |
$2,925.60
|
| Rate for Payer: NAPHCARE Commercial |
$2,194.20
|
| Rate for Payer: Preferred Network Access Commercial |
$3,364.44
|
| Rate for Payer: Quartz Beloit One Network |
$1,791.93
|
| Rate for Payer: Quartz Commercial |
$2,377.05
|
| Rate for Payer: Quartz Medicare Advantage |
$2,194.20
|
| Rate for Payer: The Alliance Commercial |
$14,628.00
|
| Rate for Payer: WEA Trust Commercial |
$2,011.35
|
| Rate for Payer: WPS Commercial |
$2,708.74
|
|
