|
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 |
$777.14 |
| Max. Negotiated Rate |
$1,459.12 |
| Rate for Payer: Aetna Commercial |
$1,427.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,363.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$840.58
|
| Rate for Payer: Cash Price |
$457.50
|
| Rate for Payer: Cigna Commercial |
$1,459.12
|
| Rate for Payer: Health EOS Commercial |
$1,411.54
|
| Rate for Payer: HFN Commercial |
$1,459.12
|
| Rate for Payer: Multiplan Commercial |
$1,268.80
|
| Rate for Payer: Preferred Network Access Commercial |
$1,459.12
|
| Rate for Payer: Quartz Beloit One Network |
$777.14
|
| Rate for Payer: Quartz Commercial |
$951.60
|
| Rate for Payer: WEA Trust Commercial |
$872.30
|
| Rate for Payer: WPS Commercial |
$1,174.71
|
|
|
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 |
$444.08 |
| Max. Negotiated Rate |
$1,459.12 |
| Rate for Payer: Aetna Commercial |
$1,427.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,363.96
|
| Rate for Payer: Aetna Managed Medicare |
$444.08
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,030.90
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$793.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$761.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$840.58
|
| Rate for Payer: Cash Price |
$457.50
|
| Rate for Payer: Cigna Commercial |
$1,459.12
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$887.55
|
| Rate for Payer: Health EOS Commercial |
$1,411.54
|
| Rate for Payer: HFN Commercial |
$1,459.12
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,189.50
|
| Rate for Payer: Multiplan Commercial |
$1,268.80
|
| Rate for Payer: NAPHCARE Commercial |
$951.60
|
| Rate for Payer: Preferred Network Access Commercial |
$1,459.12
|
| Rate for Payer: Quartz Beloit One Network |
$777.14
|
| Rate for Payer: Quartz Commercial |
$1,030.90
|
| Rate for Payer: Quartz Medicare Advantage |
$951.60
|
| Rate for Payer: The Alliance Commercial |
$793.00
|
| Rate for Payer: WEA Trust Commercial |
$872.30
|
| Rate for Payer: WPS Commercial |
$1,174.71
|
|
|
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 |
$777.14 |
| Max. Negotiated Rate |
$1,459.12 |
| Rate for Payer: Aetna Commercial |
$1,427.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,363.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$840.58
|
| Rate for Payer: Cash Price |
$457.50
|
| Rate for Payer: Cigna Commercial |
$1,459.12
|
| Rate for Payer: Health EOS Commercial |
$1,411.54
|
| Rate for Payer: HFN Commercial |
$1,459.12
|
| Rate for Payer: Multiplan Commercial |
$1,268.80
|
| Rate for Payer: Preferred Network Access Commercial |
$1,459.12
|
| Rate for Payer: Quartz Beloit One Network |
$777.14
|
| Rate for Payer: Quartz Commercial |
$951.60
|
| Rate for Payer: WEA Trust Commercial |
$872.30
|
| Rate for Payer: WPS Commercial |
$1,174.71
|
|
|
BALLOON MAVERICK MONORAIL 3.0 X 9mm
|
Facility
|
OP
|
$1,525.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
3393510
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$444.08 |
| Max. Negotiated Rate |
$1,459.12 |
| Rate for Payer: Aetna Commercial |
$1,427.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,363.96
|
| Rate for Payer: Aetna Managed Medicare |
$444.08
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,030.90
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$793.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$761.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$840.58
|
| Rate for Payer: Cash Price |
$457.50
|
| Rate for Payer: Cigna Commercial |
$1,459.12
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$887.55
|
| Rate for Payer: Health EOS Commercial |
$1,411.54
|
| Rate for Payer: HFN Commercial |
$1,459.12
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,189.50
|
| Rate for Payer: Multiplan Commercial |
$1,268.80
|
| Rate for Payer: NAPHCARE Commercial |
$951.60
|
| Rate for Payer: Preferred Network Access Commercial |
$1,459.12
|
| Rate for Payer: Quartz Beloit One Network |
$777.14
|
| Rate for Payer: Quartz Commercial |
$1,030.90
|
| Rate for Payer: Quartz Medicare Advantage |
$951.60
|
| Rate for Payer: The Alliance Commercial |
$793.00
|
| Rate for Payer: WEA Trust Commercial |
$872.30
|
| Rate for Payer: WPS Commercial |
$1,174.71
|
|
|
BALLOON MAVERICK MONORAIL 3.0 X 9mm
|
Facility
|
IP
|
$1,525.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
3393510
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$777.14 |
| Max. Negotiated Rate |
$1,459.12 |
| Rate for Payer: Aetna Commercial |
$1,427.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,363.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$840.58
|
| Rate for Payer: Cash Price |
$457.50
|
| Rate for Payer: Cigna Commercial |
$1,459.12
|
| Rate for Payer: Health EOS Commercial |
$1,411.54
|
| Rate for Payer: HFN Commercial |
$1,459.12
|
| Rate for Payer: Multiplan Commercial |
$1,268.80
|
| Rate for Payer: Preferred Network Access Commercial |
$1,459.12
|
| Rate for Payer: Quartz Beloit One Network |
$777.14
|
| Rate for Payer: Quartz Commercial |
$951.60
|
| Rate for Payer: WEA Trust Commercial |
$872.30
|
| Rate for Payer: WPS Commercial |
$1,174.71
|
|
|
BALLOON MAVERICK MONORAIL 3.5 X 15mm
|
Facility
|
IP
|
$1,525.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
3521510
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$777.14 |
| Max. Negotiated Rate |
$1,459.12 |
| Rate for Payer: Aetna Commercial |
$1,427.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,363.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$840.58
|
| Rate for Payer: Cash Price |
$457.50
|
| Rate for Payer: Cigna Commercial |
$1,459.12
|
| Rate for Payer: Health EOS Commercial |
$1,411.54
|
| Rate for Payer: HFN Commercial |
$1,459.12
|
| Rate for Payer: Multiplan Commercial |
$1,268.80
|
| Rate for Payer: Preferred Network Access Commercial |
$1,459.12
|
| Rate for Payer: Quartz Beloit One Network |
$777.14
|
| Rate for Payer: Quartz Commercial |
$951.60
|
| Rate for Payer: WEA Trust Commercial |
$872.30
|
| Rate for Payer: WPS Commercial |
$1,174.71
|
|
|
BALLOON MAVERICK MONORAIL 3.5 X 15mm
|
Facility
|
OP
|
$1,525.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
3521510
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$444.08 |
| Max. Negotiated Rate |
$1,459.12 |
| Rate for Payer: Aetna Commercial |
$1,427.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,363.96
|
| Rate for Payer: Aetna Managed Medicare |
$444.08
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,030.90
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$793.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$761.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$840.58
|
| Rate for Payer: Cash Price |
$457.50
|
| Rate for Payer: Cigna Commercial |
$1,459.12
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$887.55
|
| Rate for Payer: Health EOS Commercial |
$1,411.54
|
| Rate for Payer: HFN Commercial |
$1,459.12
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,189.50
|
| Rate for Payer: Multiplan Commercial |
$1,268.80
|
| Rate for Payer: NAPHCARE Commercial |
$951.60
|
| Rate for Payer: Preferred Network Access Commercial |
$1,459.12
|
| Rate for Payer: Quartz Beloit One Network |
$777.14
|
| Rate for Payer: Quartz Commercial |
$1,030.90
|
| Rate for Payer: Quartz Medicare Advantage |
$951.60
|
| Rate for Payer: The Alliance Commercial |
$793.00
|
| Rate for Payer: WEA Trust Commercial |
$872.30
|
| Rate for Payer: WPS Commercial |
$1,174.71
|
|
|
BALLOON MAVERICK MONORAIL 3.5 X 20mm
|
Facility
|
IP
|
$1,525.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
3393520
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$777.14 |
| Max. Negotiated Rate |
$1,459.12 |
| Rate for Payer: Aetna Commercial |
$1,427.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,363.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$840.58
|
| Rate for Payer: Cash Price |
$457.50
|
| Rate for Payer: Cigna Commercial |
$1,459.12
|
| Rate for Payer: Health EOS Commercial |
$1,411.54
|
| Rate for Payer: HFN Commercial |
$1,459.12
|
| Rate for Payer: Multiplan Commercial |
$1,268.80
|
| Rate for Payer: Preferred Network Access Commercial |
$1,459.12
|
| Rate for Payer: Quartz Beloit One Network |
$777.14
|
| Rate for Payer: Quartz Commercial |
$951.60
|
| Rate for Payer: WEA Trust Commercial |
$872.30
|
| Rate for Payer: WPS Commercial |
$1,174.71
|
|
|
BALLOON MAVERICK MONORAIL 3.5 X 20mm
|
Facility
|
OP
|
$1,525.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
3393520
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$444.08 |
| Max. Negotiated Rate |
$1,459.12 |
| Rate for Payer: Aetna Commercial |
$1,427.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,363.96
|
| Rate for Payer: Aetna Managed Medicare |
$444.08
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,030.90
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$793.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$761.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$840.58
|
| Rate for Payer: Cash Price |
$457.50
|
| Rate for Payer: Cigna Commercial |
$1,459.12
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$887.55
|
| Rate for Payer: Health EOS Commercial |
$1,411.54
|
| Rate for Payer: HFN Commercial |
$1,459.12
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,189.50
|
| Rate for Payer: Multiplan Commercial |
$1,268.80
|
| Rate for Payer: NAPHCARE Commercial |
$951.60
|
| Rate for Payer: Preferred Network Access Commercial |
$1,459.12
|
| Rate for Payer: Quartz Beloit One Network |
$777.14
|
| Rate for Payer: Quartz Commercial |
$1,030.90
|
| Rate for Payer: Quartz Medicare Advantage |
$951.60
|
| Rate for Payer: The Alliance Commercial |
$793.00
|
| Rate for Payer: WEA Trust Commercial |
$872.30
|
| Rate for Payer: WPS Commercial |
$1,174.71
|
|
|
BALLOON MAVERICK MONORAIL 3.5 X 9mm
|
Facility
|
OP
|
$1,525.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
3393519
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$444.08 |
| Max. Negotiated Rate |
$1,459.12 |
| Rate for Payer: Aetna Commercial |
$1,427.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,363.96
|
| Rate for Payer: Aetna Managed Medicare |
$444.08
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,030.90
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$793.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$761.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$840.58
|
| Rate for Payer: Cash Price |
$457.50
|
| Rate for Payer: Cigna Commercial |
$1,459.12
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$887.55
|
| Rate for Payer: Health EOS Commercial |
$1,411.54
|
| Rate for Payer: HFN Commercial |
$1,459.12
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,189.50
|
| Rate for Payer: Multiplan Commercial |
$1,268.80
|
| Rate for Payer: NAPHCARE Commercial |
$951.60
|
| Rate for Payer: Preferred Network Access Commercial |
$1,459.12
|
| Rate for Payer: Quartz Beloit One Network |
$777.14
|
| Rate for Payer: Quartz Commercial |
$1,030.90
|
| Rate for Payer: Quartz Medicare Advantage |
$951.60
|
| Rate for Payer: The Alliance Commercial |
$793.00
|
| Rate for Payer: WEA Trust Commercial |
$872.30
|
| Rate for Payer: WPS Commercial |
$1,174.71
|
|
|
BALLOON MAVERICK MONORAIL 3.5 X 9mm
|
Facility
|
IP
|
$1,525.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
3393519
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$777.14 |
| Max. Negotiated Rate |
$1,459.12 |
| Rate for Payer: Aetna Commercial |
$1,427.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,363.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$840.58
|
| Rate for Payer: Cash Price |
$457.50
|
| Rate for Payer: Cigna Commercial |
$1,459.12
|
| Rate for Payer: Health EOS Commercial |
$1,411.54
|
| Rate for Payer: HFN Commercial |
$1,459.12
|
| Rate for Payer: Multiplan Commercial |
$1,268.80
|
| Rate for Payer: Preferred Network Access Commercial |
$1,459.12
|
| Rate for Payer: Quartz Beloit One Network |
$777.14
|
| Rate for Payer: Quartz Commercial |
$951.60
|
| Rate for Payer: WEA Trust Commercial |
$872.30
|
| Rate for Payer: WPS Commercial |
$1,174.71
|
|
|
BALLOON MAVERICK MONORAIL 4.0 X 15mm
|
Facility
|
OP
|
$1,525.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
3393524
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$444.08 |
| Max. Negotiated Rate |
$1,459.12 |
| Rate for Payer: Aetna Commercial |
$1,427.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,363.96
|
| Rate for Payer: Aetna Managed Medicare |
$444.08
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,030.90
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$793.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$761.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$840.58
|
| Rate for Payer: Cash Price |
$457.50
|
| Rate for Payer: Cigna Commercial |
$1,459.12
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$887.55
|
| Rate for Payer: Health EOS Commercial |
$1,411.54
|
| Rate for Payer: HFN Commercial |
$1,459.12
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,189.50
|
| Rate for Payer: Multiplan Commercial |
$1,268.80
|
| Rate for Payer: NAPHCARE Commercial |
$951.60
|
| Rate for Payer: Preferred Network Access Commercial |
$1,459.12
|
| Rate for Payer: Quartz Beloit One Network |
$777.14
|
| Rate for Payer: Quartz Commercial |
$1,030.90
|
| Rate for Payer: Quartz Medicare Advantage |
$951.60
|
| Rate for Payer: The Alliance Commercial |
$793.00
|
| Rate for Payer: WEA Trust Commercial |
$872.30
|
| Rate for Payer: WPS Commercial |
$1,174.71
|
|
|
BALLOON MAVERICK MONORAIL 4.0 X 15mm
|
Facility
|
IP
|
$1,525.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
3393524
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$777.14 |
| Max. Negotiated Rate |
$1,459.12 |
| Rate for Payer: Aetna Commercial |
$1,427.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,363.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$840.58
|
| Rate for Payer: Cash Price |
$457.50
|
| Rate for Payer: Cigna Commercial |
$1,459.12
|
| Rate for Payer: Health EOS Commercial |
$1,411.54
|
| Rate for Payer: HFN Commercial |
$1,459.12
|
| Rate for Payer: Multiplan Commercial |
$1,268.80
|
| Rate for Payer: Preferred Network Access Commercial |
$1,459.12
|
| Rate for Payer: Quartz Beloit One Network |
$777.14
|
| Rate for Payer: Quartz Commercial |
$951.60
|
| Rate for Payer: WEA Trust Commercial |
$872.30
|
| Rate for Payer: WPS Commercial |
$1,174.71
|
|
|
BALLOON MAVERICK MONORAIL 4.0 X 20mm
|
Facility
|
IP
|
$1,525.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
3393525
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$777.14 |
| Max. Negotiated Rate |
$1,459.12 |
| Rate for Payer: Aetna Commercial |
$1,427.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,363.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$840.58
|
| Rate for Payer: Cash Price |
$457.50
|
| Rate for Payer: Cigna Commercial |
$1,459.12
|
| Rate for Payer: Health EOS Commercial |
$1,411.54
|
| Rate for Payer: HFN Commercial |
$1,459.12
|
| Rate for Payer: Multiplan Commercial |
$1,268.80
|
| Rate for Payer: Preferred Network Access Commercial |
$1,459.12
|
| Rate for Payer: Quartz Beloit One Network |
$777.14
|
| Rate for Payer: Quartz Commercial |
$951.60
|
| Rate for Payer: WEA Trust Commercial |
$872.30
|
| Rate for Payer: WPS Commercial |
$1,174.71
|
|
|
BALLOON MAVERICK MONORAIL 4.0 X 20mm
|
Facility
|
OP
|
$1,525.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
3393525
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$444.08 |
| Max. Negotiated Rate |
$1,459.12 |
| Rate for Payer: Aetna Commercial |
$1,427.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,363.96
|
| Rate for Payer: Aetna Managed Medicare |
$444.08
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,030.90
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$793.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$761.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$840.58
|
| Rate for Payer: Cash Price |
$457.50
|
| Rate for Payer: Cigna Commercial |
$1,459.12
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$887.55
|
| Rate for Payer: Health EOS Commercial |
$1,411.54
|
| Rate for Payer: HFN Commercial |
$1,459.12
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,189.50
|
| Rate for Payer: Multiplan Commercial |
$1,268.80
|
| Rate for Payer: NAPHCARE Commercial |
$951.60
|
| Rate for Payer: Preferred Network Access Commercial |
$1,459.12
|
| Rate for Payer: Quartz Beloit One Network |
$777.14
|
| Rate for Payer: Quartz Commercial |
$1,030.90
|
| Rate for Payer: Quartz Medicare Advantage |
$951.60
|
| Rate for Payer: The Alliance Commercial |
$793.00
|
| Rate for Payer: WEA Trust Commercial |
$872.30
|
| Rate for Payer: WPS Commercial |
$1,174.71
|
|
|
BALLOON MAVERICK MONORAIL 4.0 X 9mm
|
Facility
|
IP
|
$1,525.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
3393523
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$777.14 |
| Max. Negotiated Rate |
$1,459.12 |
| Rate for Payer: Aetna Commercial |
$1,427.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,363.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$840.58
|
| Rate for Payer: Cash Price |
$457.50
|
| Rate for Payer: Cigna Commercial |
$1,459.12
|
| Rate for Payer: Health EOS Commercial |
$1,411.54
|
| Rate for Payer: HFN Commercial |
$1,459.12
|
| Rate for Payer: Multiplan Commercial |
$1,268.80
|
| Rate for Payer: Preferred Network Access Commercial |
$1,459.12
|
| Rate for Payer: Quartz Beloit One Network |
$777.14
|
| Rate for Payer: Quartz Commercial |
$951.60
|
| Rate for Payer: WEA Trust Commercial |
$872.30
|
| Rate for Payer: WPS Commercial |
$1,174.71
|
|
|
BALLOON MAVERICK MONORAIL 4.0 X 9mm
|
Facility
|
OP
|
$1,525.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
3393523
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$444.08 |
| Max. Negotiated Rate |
$1,459.12 |
| Rate for Payer: Aetna Commercial |
$1,427.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,363.96
|
| Rate for Payer: Aetna Managed Medicare |
$444.08
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,030.90
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$793.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$761.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$840.58
|
| Rate for Payer: Cash Price |
$457.50
|
| Rate for Payer: Cigna Commercial |
$1,459.12
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$887.55
|
| Rate for Payer: Health EOS Commercial |
$1,411.54
|
| Rate for Payer: HFN Commercial |
$1,459.12
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,189.50
|
| Rate for Payer: Multiplan Commercial |
$1,268.80
|
| Rate for Payer: NAPHCARE Commercial |
$951.60
|
| Rate for Payer: Preferred Network Access Commercial |
$1,459.12
|
| Rate for Payer: Quartz Beloit One Network |
$777.14
|
| Rate for Payer: Quartz Commercial |
$1,030.90
|
| Rate for Payer: Quartz Medicare Advantage |
$951.60
|
| Rate for Payer: The Alliance Commercial |
$793.00
|
| Rate for Payer: WEA Trust Commercial |
$872.30
|
| Rate for Payer: WPS Commercial |
$1,174.71
|
|
|
BALLOON MUSTANG 10.0x 40x 75cm #3917110047
|
Facility
|
IP
|
$3,842.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
2973451
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,957.88 |
| Max. Negotiated Rate |
$3,676.03 |
| Rate for Payer: Aetna Commercial |
$3,596.11
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,436.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,117.71
|
| Rate for Payer: Cash Price |
$1,152.60
|
| Rate for Payer: Cigna Commercial |
$3,676.03
|
| Rate for Payer: Health EOS Commercial |
$3,556.16
|
| Rate for Payer: HFN Commercial |
$3,676.03
|
| Rate for Payer: Multiplan Commercial |
$3,196.54
|
| Rate for Payer: Preferred Network Access Commercial |
$3,676.03
|
| Rate for Payer: Quartz Beloit One Network |
$1,957.88
|
| Rate for Payer: Quartz Commercial |
$2,397.41
|
| Rate for Payer: WEA Trust Commercial |
$2,197.62
|
| Rate for Payer: WPS Commercial |
$2,959.49
|
|
|
BALLOON MUSTANG 10.0x 40x 75cm #3917110047
|
Facility
|
OP
|
$3,842.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
2973451
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,118.79 |
| Max. Negotiated Rate |
$3,676.03 |
| Rate for Payer: Aetna Commercial |
$3,596.11
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,436.28
|
| Rate for Payer: Aetna Managed Medicare |
$1,118.79
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,597.19
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,997.84
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,917.93
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,117.71
|
| Rate for Payer: Cash Price |
$1,152.60
|
| Rate for Payer: Cigna Commercial |
$3,676.03
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,236.04
|
| Rate for Payer: Health EOS Commercial |
$3,556.16
|
| Rate for Payer: HFN Commercial |
$3,676.03
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,996.76
|
| Rate for Payer: Multiplan Commercial |
$3,196.54
|
| Rate for Payer: NAPHCARE Commercial |
$2,397.41
|
| Rate for Payer: Preferred Network Access Commercial |
$3,676.03
|
| Rate for Payer: Quartz Beloit One Network |
$1,957.88
|
| Rate for Payer: Quartz Commercial |
$2,597.19
|
| Rate for Payer: Quartz Medicare Advantage |
$2,397.41
|
| Rate for Payer: The Alliance Commercial |
$1,997.84
|
| Rate for Payer: WEA Trust Commercial |
$2,197.62
|
| Rate for Payer: WPS Commercial |
$2,959.49
|
|
|
BALLOON MUSTANG 12.0 x 40x 75cm #3917112047
|
Facility
|
IP
|
$3,842.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
2973452
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,957.88 |
| Max. Negotiated Rate |
$3,676.03 |
| Rate for Payer: Aetna Commercial |
$3,596.11
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,436.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,117.71
|
| Rate for Payer: Cash Price |
$1,152.60
|
| Rate for Payer: Cigna Commercial |
$3,676.03
|
| Rate for Payer: Health EOS Commercial |
$3,556.16
|
| Rate for Payer: HFN Commercial |
$3,676.03
|
| Rate for Payer: Multiplan Commercial |
$3,196.54
|
| Rate for Payer: Preferred Network Access Commercial |
$3,676.03
|
| Rate for Payer: Quartz Beloit One Network |
$1,957.88
|
| Rate for Payer: Quartz Commercial |
$2,397.41
|
| Rate for Payer: WEA Trust Commercial |
$2,197.62
|
| Rate for Payer: WPS Commercial |
$2,959.49
|
|
|
BALLOON MUSTANG 12.0 x 40x 75cm #3917112047
|
Facility
|
OP
|
$3,842.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
2973452
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,118.79 |
| Max. Negotiated Rate |
$3,676.03 |
| Rate for Payer: Aetna Commercial |
$3,596.11
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,436.28
|
| Rate for Payer: Aetna Managed Medicare |
$1,118.79
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,597.19
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,997.84
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,917.93
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,117.71
|
| Rate for Payer: Cash Price |
$1,152.60
|
| Rate for Payer: Cigna Commercial |
$3,676.03
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,236.04
|
| Rate for Payer: Health EOS Commercial |
$3,556.16
|
| Rate for Payer: HFN Commercial |
$3,676.03
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,996.76
|
| Rate for Payer: Multiplan Commercial |
$3,196.54
|
| Rate for Payer: NAPHCARE Commercial |
$2,397.41
|
| Rate for Payer: Preferred Network Access Commercial |
$3,676.03
|
| Rate for Payer: Quartz Beloit One Network |
$1,957.88
|
| Rate for Payer: Quartz Commercial |
$2,597.19
|
| Rate for Payer: Quartz Medicare Advantage |
$2,397.41
|
| Rate for Payer: The Alliance Commercial |
$1,997.84
|
| Rate for Payer: WEA Trust Commercial |
$2,197.62
|
| Rate for Payer: WPS Commercial |
$2,959.49
|
|
|
BALLOON MUSTANG 4.0 x 20x 75cm
|
Facility
|
IP
|
$3,842.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
2973445
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,957.88 |
| Max. Negotiated Rate |
$3,676.03 |
| Rate for Payer: Aetna Commercial |
$3,596.11
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,436.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,117.71
|
| Rate for Payer: Cash Price |
$1,152.60
|
| Rate for Payer: Cigna Commercial |
$3,676.03
|
| Rate for Payer: Health EOS Commercial |
$3,556.16
|
| Rate for Payer: HFN Commercial |
$3,676.03
|
| Rate for Payer: Multiplan Commercial |
$3,196.54
|
| Rate for Payer: Preferred Network Access Commercial |
$3,676.03
|
| Rate for Payer: Quartz Beloit One Network |
$1,957.88
|
| Rate for Payer: Quartz Commercial |
$2,397.41
|
| Rate for Payer: WEA Trust Commercial |
$2,197.62
|
| Rate for Payer: WPS Commercial |
$2,959.49
|
|
|
BALLOON MUSTANG 4.0 x 20x 75cm
|
Facility
|
OP
|
$3,842.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
2973445
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,118.79 |
| Max. Negotiated Rate |
$3,676.03 |
| Rate for Payer: Aetna Commercial |
$3,596.11
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,436.28
|
| Rate for Payer: Aetna Managed Medicare |
$1,118.79
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,597.19
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,997.84
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,917.93
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,117.71
|
| Rate for Payer: Cash Price |
$1,152.60
|
| Rate for Payer: Cigna Commercial |
$3,676.03
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,236.04
|
| Rate for Payer: Health EOS Commercial |
$3,556.16
|
| Rate for Payer: HFN Commercial |
$3,676.03
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,996.76
|
| Rate for Payer: Multiplan Commercial |
$3,196.54
|
| Rate for Payer: NAPHCARE Commercial |
$2,397.41
|
| Rate for Payer: Preferred Network Access Commercial |
$3,676.03
|
| Rate for Payer: Quartz Beloit One Network |
$1,957.88
|
| Rate for Payer: Quartz Commercial |
$2,597.19
|
| Rate for Payer: Quartz Medicare Advantage |
$2,397.41
|
| Rate for Payer: The Alliance Commercial |
$1,997.84
|
| Rate for Payer: WEA Trust Commercial |
$2,197.62
|
| Rate for Payer: WPS Commercial |
$2,959.49
|
|
|
BALLOON MUSTANG 4 x 40x 40CM 39171-04044
|
Facility
|
IP
|
$3,956.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
3467505
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$2,015.98 |
| Max. Negotiated Rate |
$3,785.10 |
| Rate for Payer: Aetna Commercial |
$3,702.82
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,538.25
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,180.55
|
| Rate for Payer: Cash Price |
$1,186.80
|
| Rate for Payer: Cigna Commercial |
$3,785.10
|
| Rate for Payer: Health EOS Commercial |
$3,661.67
|
| Rate for Payer: HFN Commercial |
$3,785.10
|
| Rate for Payer: Multiplan Commercial |
$3,291.39
|
| Rate for Payer: Preferred Network Access Commercial |
$3,785.10
|
| Rate for Payer: Quartz Beloit One Network |
$2,015.98
|
| Rate for Payer: Quartz Commercial |
$2,468.54
|
| Rate for Payer: WEA Trust Commercial |
$2,262.83
|
| Rate for Payer: WPS Commercial |
$3,047.31
|
|
|
BALLOON MUSTANG 4 x 40x 40CM 39171-04044
|
Facility
|
OP
|
$3,956.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
3467505
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,151.99 |
| Max. Negotiated Rate |
$3,785.10 |
| Rate for Payer: Aetna Commercial |
$3,702.82
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,538.25
|
| Rate for Payer: Aetna Managed Medicare |
$1,151.99
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,674.26
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,057.12
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,974.84
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,180.55
|
| Rate for Payer: Cash Price |
$1,186.80
|
| Rate for Payer: Cigna Commercial |
$3,785.10
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,302.39
|
| Rate for Payer: Health EOS Commercial |
$3,661.67
|
| Rate for Payer: HFN Commercial |
$3,785.10
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,085.68
|
| Rate for Payer: Multiplan Commercial |
$3,291.39
|
| Rate for Payer: NAPHCARE Commercial |
$2,468.54
|
| Rate for Payer: Preferred Network Access Commercial |
$3,785.10
|
| Rate for Payer: Quartz Beloit One Network |
$2,015.98
|
| Rate for Payer: Quartz Commercial |
$2,674.26
|
| Rate for Payer: Quartz Medicare Advantage |
$2,468.54
|
| Rate for Payer: The Alliance Commercial |
$2,057.12
|
| Rate for Payer: WEA Trust Commercial |
$2,262.83
|
| Rate for Payer: WPS Commercial |
$3,047.31
|
|
