|
VEST SMALL AIRWAY CLEARAN #P300630000
|
Facility
|
IP
|
$1,484.00
|
|
| Hospital Charge Code |
2972254
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$727.16 |
| Max. Negotiated Rate |
$1,365.28 |
| Rate for Payer: Aetna Commercial |
$1,335.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,276.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$786.52
|
| Rate for Payer: Cash Price |
$445.20
|
| Rate for Payer: Cigna Commercial |
$1,365.28
|
| Rate for Payer: Health EOS Commercial |
$1,320.76
|
| Rate for Payer: HFN Commercial |
$1,365.28
|
| Rate for Payer: Multiplan Commercial |
$1,187.20
|
| Rate for Payer: NAPHCARE Commercial |
$890.40
|
| Rate for Payer: Preferred Network Access Commercial |
$1,365.28
|
| Rate for Payer: Quartz Beloit One Network |
$727.16
|
| Rate for Payer: Quartz Commercial |
$890.40
|
| Rate for Payer: WEA Trust Commercial |
$816.20
|
| Rate for Payer: WPS Commercial |
$1,099.20
|
|
|
VEST X-LRG AIRWAY CLEARAN #P300633000
|
Facility
|
IP
|
$1,484.00
|
|
| Hospital Charge Code |
2972307
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$727.16 |
| Max. Negotiated Rate |
$1,365.28 |
| Rate for Payer: Aetna Commercial |
$1,335.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,276.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$786.52
|
| Rate for Payer: Cash Price |
$445.20
|
| Rate for Payer: Cigna Commercial |
$1,365.28
|
| Rate for Payer: Health EOS Commercial |
$1,320.76
|
| Rate for Payer: HFN Commercial |
$1,365.28
|
| Rate for Payer: Multiplan Commercial |
$1,187.20
|
| Rate for Payer: NAPHCARE Commercial |
$890.40
|
| Rate for Payer: Preferred Network Access Commercial |
$1,365.28
|
| Rate for Payer: Quartz Beloit One Network |
$727.16
|
| Rate for Payer: Quartz Commercial |
$890.40
|
| Rate for Payer: WEA Trust Commercial |
$816.20
|
| Rate for Payer: WPS Commercial |
$1,099.20
|
|
|
VEST X-LRG AIRWAY CLEARAN #P300633000
|
Facility
|
OP
|
$1,484.00
|
|
| Hospital Charge Code |
2972307
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$415.52 |
| Max. Negotiated Rate |
$5,936.00 |
| Rate for Payer: Aetna Commercial |
$1,335.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,276.24
|
| Rate for Payer: Aetna Managed Medicare |
$415.52
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$964.60
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$742.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$712.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$786.52
|
| Rate for Payer: Cash Price |
$445.20
|
| Rate for Payer: Cigna Commercial |
$1,365.28
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$830.45
|
| Rate for Payer: Health EOS Commercial |
$1,320.76
|
| Rate for Payer: HFN Commercial |
$1,365.28
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,113.00
|
| Rate for Payer: Multiplan Commercial |
$1,187.20
|
| Rate for Payer: NAPHCARE Commercial |
$890.40
|
| Rate for Payer: Preferred Network Access Commercial |
$1,365.28
|
| Rate for Payer: Quartz Beloit One Network |
$727.16
|
| Rate for Payer: Quartz Commercial |
$964.60
|
| Rate for Payer: Quartz Medicare Advantage |
$890.40
|
| Rate for Payer: The Alliance Commercial |
$5,936.00
|
| Rate for Payer: WEA Trust Commercial |
$816.20
|
| Rate for Payer: WPS Commercial |
$1,099.20
|
|
|
VFC Beyfortus 100mg/ml Charge 90381
|
Facility
|
IP
|
$20.83
|
|
|
Service Code
|
CPT 90381
|
| Hospital Charge Code |
6238125
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$10.21 |
| Max. Negotiated Rate |
$19.16 |
| Rate for Payer: Aetna Commercial |
$18.75
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$17.91
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$11.04
|
| Rate for Payer: Cash Price |
$6.25
|
| Rate for Payer: Cigna Commercial |
$19.16
|
| Rate for Payer: Health EOS Commercial |
$18.54
|
| Rate for Payer: HFN Commercial |
$19.16
|
| Rate for Payer: Multiplan Commercial |
$16.66
|
| Rate for Payer: NAPHCARE Commercial |
$12.50
|
| Rate for Payer: Preferred Network Access Commercial |
$19.16
|
| Rate for Payer: Quartz Beloit One Network |
$10.21
|
| Rate for Payer: Quartz Commercial |
$12.50
|
| Rate for Payer: WEA Trust Commercial |
$11.46
|
| Rate for Payer: WPS Commercial |
$15.43
|
|
|
VFC Beyfortus 100mg/ml Charge 90381
|
Professional
|
Both
|
$20.83
|
|
|
Service Code
|
CPT 90381
|
| Hospital Charge Code |
6238125
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$9.17 |
| Max. Negotiated Rate |
$19.79 |
| Rate for Payer: Aetna Commercial |
$19.79
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$17.91
|
| Rate for Payer: Cash Price |
$6.25
|
| Rate for Payer: Cigna Commercial |
$19.79
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$12.50
|
| Rate for Payer: Health EOS Commercial |
$18.96
|
| Rate for Payer: HFN Commercial |
$19.79
|
| Rate for Payer: Multiplan Commercial |
$16.66
|
| Rate for Payer: Preferred Network Access Commercial |
$19.79
|
| Rate for Payer: Quartz Beloit One Network |
$9.17
|
| Rate for Payer: Quartz Commercial |
$11.87
|
| Rate for Payer: The Alliance Commercial |
$10.42
|
| Rate for Payer: WEA Trust Commercial |
$11.46
|
| Rate for Payer: WPS Commercial |
$15.43
|
|
|
VFC Beyfortus 100mg/ml Charge 90381
|
Facility
|
OP
|
$20.83
|
|
|
Service Code
|
CPT 90381
|
| Hospital Charge Code |
6238125
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$5.83 |
| Max. Negotiated Rate |
$83.32 |
| Rate for Payer: Aetna Commercial |
$18.75
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$17.91
|
| Rate for Payer: Aetna Managed Medicare |
$5.83
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$13.54
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$10.42
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$10.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$11.04
|
| Rate for Payer: Cash Price |
$6.25
|
| Rate for Payer: Cigna Commercial |
$19.16
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$11.66
|
| Rate for Payer: Health EOS Commercial |
$18.54
|
| Rate for Payer: HFN Commercial |
$19.16
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$15.62
|
| Rate for Payer: Multiplan Commercial |
$16.66
|
| Rate for Payer: NAPHCARE Commercial |
$12.50
|
| Rate for Payer: Preferred Network Access Commercial |
$19.16
|
| Rate for Payer: Quartz Beloit One Network |
$10.21
|
| Rate for Payer: Quartz Commercial |
$13.54
|
| Rate for Payer: Quartz Medicare Advantage |
$12.50
|
| Rate for Payer: The Alliance Commercial |
$83.32
|
| Rate for Payer: WEA Trust Commercial |
$11.46
|
| Rate for Payer: WPS Commercial |
$15.43
|
|
|
VFC Beyfortus 50mg Charge 90380
|
Facility
|
OP
|
$20.83
|
|
|
Service Code
|
CPT 90380
|
| Hospital Charge Code |
6238126
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$5.83 |
| Max. Negotiated Rate |
$83.32 |
| Rate for Payer: Aetna Commercial |
$18.75
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$17.91
|
| Rate for Payer: Aetna Managed Medicare |
$5.83
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$13.54
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$10.42
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$10.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$11.04
|
| Rate for Payer: Cash Price |
$6.25
|
| Rate for Payer: Cigna Commercial |
$19.16
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$11.66
|
| Rate for Payer: Health EOS Commercial |
$18.54
|
| Rate for Payer: HFN Commercial |
$19.16
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$15.62
|
| Rate for Payer: Multiplan Commercial |
$16.66
|
| Rate for Payer: NAPHCARE Commercial |
$12.50
|
| Rate for Payer: Preferred Network Access Commercial |
$19.16
|
| Rate for Payer: Quartz Beloit One Network |
$10.21
|
| Rate for Payer: Quartz Commercial |
$13.54
|
| Rate for Payer: Quartz Medicare Advantage |
$12.50
|
| Rate for Payer: The Alliance Commercial |
$83.32
|
| Rate for Payer: WEA Trust Commercial |
$11.46
|
| Rate for Payer: WPS Commercial |
$15.43
|
|
|
VFC Beyfortus 50mg Charge 90380
|
Professional
|
Both
|
$20.83
|
|
|
Service Code
|
CPT 90380
|
| Hospital Charge Code |
6238126
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$9.17 |
| Max. Negotiated Rate |
$19.79 |
| Rate for Payer: Aetna Commercial |
$19.79
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$17.91
|
| Rate for Payer: Cash Price |
$6.25
|
| Rate for Payer: Cigna Commercial |
$19.79
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$12.50
|
| Rate for Payer: Health EOS Commercial |
$18.96
|
| Rate for Payer: HFN Commercial |
$19.79
|
| Rate for Payer: Multiplan Commercial |
$16.66
|
| Rate for Payer: Preferred Network Access Commercial |
$19.79
|
| Rate for Payer: Quartz Beloit One Network |
$9.17
|
| Rate for Payer: Quartz Commercial |
$11.87
|
| Rate for Payer: The Alliance Commercial |
$10.42
|
| Rate for Payer: WEA Trust Commercial |
$11.46
|
| Rate for Payer: WPS Commercial |
$15.43
|
|
|
VFC Beyfortus 50mg Charge 90380
|
Facility
|
IP
|
$20.83
|
|
|
Service Code
|
CPT 90380
|
| Hospital Charge Code |
6238126
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$10.21 |
| Max. Negotiated Rate |
$19.16 |
| Rate for Payer: Aetna Commercial |
$18.75
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$17.91
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$11.04
|
| Rate for Payer: Cash Price |
$6.25
|
| Rate for Payer: Cigna Commercial |
$19.16
|
| Rate for Payer: Health EOS Commercial |
$18.54
|
| Rate for Payer: HFN Commercial |
$19.16
|
| Rate for Payer: Multiplan Commercial |
$16.66
|
| Rate for Payer: NAPHCARE Commercial |
$12.50
|
| Rate for Payer: Preferred Network Access Commercial |
$19.16
|
| Rate for Payer: Quartz Beloit One Network |
$10.21
|
| Rate for Payer: Quartz Commercial |
$12.50
|
| Rate for Payer: WEA Trust Commercial |
$11.46
|
| Rate for Payer: WPS Commercial |
$15.43
|
|
|
VFC Fluzone PF (0.5ml) 6mo-19yr - Flu Virus, Inactivated Charge
|
Professional
|
Both
|
$22.00
|
|
|
Service Code
|
CPT 90686
|
| Hospital Charge Code |
5609709
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$9.68 |
| Max. Negotiated Rate |
$55.88 |
| Rate for Payer: Aetna Commercial |
$20.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$18.92
|
| Rate for Payer: Cash Price |
$6.60
|
| Rate for Payer: Cash Price |
$6.60
|
| Rate for Payer: Cigna Commercial |
$20.90
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$37.35
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$22.35
|
| Rate for Payer: Health EOS Commercial |
$20.02
|
| Rate for Payer: HFN Commercial |
$20.90
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$28.59
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$28.59
|
| Rate for Payer: Multiplan Commercial |
$17.60
|
| Rate for Payer: Preferred Network Access Commercial |
$20.90
|
| Rate for Payer: Quartz Beloit One Network |
$9.68
|
| Rate for Payer: Quartz Commercial |
$12.54
|
| Rate for Payer: The Alliance Commercial |
$11.00
|
| Rate for Payer: United Healthcare Medicaid |
$37.35
|
| Rate for Payer: WEA Trust Commercial |
$12.10
|
| Rate for Payer: WPS Commercial |
$55.88
|
|
|
VFC Fluzone PF (0.5ml) 6mo-19yr - Flu Virus, Inactivated Charge
|
Facility
|
OP
|
$22.00
|
|
|
Service Code
|
CPT 90686
|
| Hospital Charge Code |
5609709
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$6.16 |
| Max. Negotiated Rate |
$88.00 |
| Rate for Payer: Aetna Commercial |
$19.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$18.92
|
| Rate for Payer: Aetna Managed Medicare |
$6.16
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$14.30
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$11.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$10.56
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$11.66
|
| Rate for Payer: Cash Price |
$6.60
|
| Rate for Payer: Cash Price |
$6.60
|
| Rate for Payer: Cigna Commercial |
$20.24
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$29.57
|
| Rate for Payer: Health EOS Commercial |
$19.58
|
| Rate for Payer: HFN Commercial |
$20.24
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$16.50
|
| Rate for Payer: Multiplan Commercial |
$17.60
|
| Rate for Payer: NAPHCARE Commercial |
$13.20
|
| Rate for Payer: Preferred Network Access Commercial |
$20.24
|
| Rate for Payer: Quartz Beloit One Network |
$10.78
|
| Rate for Payer: Quartz Commercial |
$14.30
|
| Rate for Payer: Quartz Medicare Advantage |
$13.20
|
| Rate for Payer: The Alliance Commercial |
$88.00
|
| Rate for Payer: WEA Trust Commercial |
$12.10
|
| Rate for Payer: WPS Commercial |
$55.88
|
|
|
VFC Fluzone PF (0.5ml) 6mo-19yr - Flu Virus, Inactivated Charge
|
Facility
|
IP
|
$22.00
|
|
|
Service Code
|
CPT 90686
|
| Hospital Charge Code |
5609709
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$10.78 |
| Max. Negotiated Rate |
$20.24 |
| Rate for Payer: Aetna Commercial |
$19.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$18.92
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$11.66
|
| Rate for Payer: Cash Price |
$6.60
|
| Rate for Payer: Cigna Commercial |
$20.24
|
| Rate for Payer: Health EOS Commercial |
$19.58
|
| Rate for Payer: HFN Commercial |
$20.24
|
| Rate for Payer: Multiplan Commercial |
$17.60
|
| Rate for Payer: NAPHCARE Commercial |
$13.20
|
| Rate for Payer: Preferred Network Access Commercial |
$20.24
|
| Rate for Payer: Quartz Beloit One Network |
$10.78
|
| Rate for Payer: Quartz Commercial |
$13.20
|
| Rate for Payer: WEA Trust Commercial |
$12.10
|
| Rate for Payer: WPS Commercial |
$16.30
|
|
|
VFC Moderna 25mcg/0.25ML (6m-11yr) - Covid Vaccine
|
Facility
|
IP
|
$20.83
|
|
|
Service Code
|
CPT 91321
|
| Hospital Charge Code |
6230234
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$10.21 |
| Max. Negotiated Rate |
$19.16 |
| Rate for Payer: Aetna Commercial |
$18.75
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$17.91
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$11.04
|
| Rate for Payer: Cash Price |
$6.25
|
| Rate for Payer: Cigna Commercial |
$19.16
|
| Rate for Payer: Health EOS Commercial |
$18.54
|
| Rate for Payer: HFN Commercial |
$19.16
|
| Rate for Payer: Multiplan Commercial |
$16.66
|
| Rate for Payer: NAPHCARE Commercial |
$12.50
|
| Rate for Payer: Preferred Network Access Commercial |
$19.16
|
| Rate for Payer: Quartz Beloit One Network |
$10.21
|
| Rate for Payer: Quartz Commercial |
$12.50
|
| Rate for Payer: WEA Trust Commercial |
$11.46
|
| Rate for Payer: WPS Commercial |
$15.43
|
|
|
VFC Moderna 25mcg/0.25ML (6m-11yr) - Covid Vaccine
|
Facility
|
OP
|
$20.83
|
|
|
Service Code
|
CPT 91321
|
| Hospital Charge Code |
6230234
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$5.83 |
| Max. Negotiated Rate |
$364.80 |
| Rate for Payer: Aetna Commercial |
$18.75
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$17.91
|
| Rate for Payer: Aetna Managed Medicare |
$5.83
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$13.54
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$10.42
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$10.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$11.04
|
| Rate for Payer: Cash Price |
$6.25
|
| Rate for Payer: Cash Price |
$6.25
|
| Rate for Payer: Cigna Commercial |
$19.16
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$193.05
|
| Rate for Payer: Health EOS Commercial |
$18.54
|
| Rate for Payer: HFN Commercial |
$19.16
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$15.62
|
| Rate for Payer: Multiplan Commercial |
$16.66
|
| Rate for Payer: NAPHCARE Commercial |
$12.50
|
| Rate for Payer: Preferred Network Access Commercial |
$19.16
|
| Rate for Payer: Quartz Beloit One Network |
$10.21
|
| Rate for Payer: Quartz Commercial |
$13.54
|
| Rate for Payer: Quartz Medicare Advantage |
$12.50
|
| Rate for Payer: The Alliance Commercial |
$83.32
|
| Rate for Payer: WEA Trust Commercial |
$11.46
|
| Rate for Payer: WPS Commercial |
$364.80
|
|
|
VFC Moderna 25mcg/0.25ML (6m-11yr) - Covid Vaccine
|
Professional
|
Both
|
$20.83
|
|
|
Service Code
|
CPT 91321
|
| Hospital Charge Code |
6230234
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$9.17 |
| Max. Negotiated Rate |
$364.80 |
| Rate for Payer: Aetna Commercial |
$19.79
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$17.91
|
| Rate for Payer: Cash Price |
$6.25
|
| Rate for Payer: Cash Price |
$6.25
|
| Rate for Payer: Cigna Commercial |
$19.79
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$10.42
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$145.92
|
| Rate for Payer: Health EOS Commercial |
$18.96
|
| Rate for Payer: HFN Commercial |
$19.79
|
| Rate for Payer: Multiplan Commercial |
$16.66
|
| Rate for Payer: Preferred Network Access Commercial |
$19.79
|
| Rate for Payer: Quartz Beloit One Network |
$9.17
|
| Rate for Payer: Quartz Commercial |
$11.87
|
| Rate for Payer: The Alliance Commercial |
$10.42
|
| Rate for Payer: WEA Trust Commercial |
$11.46
|
| Rate for Payer: WPS Commercial |
$364.80
|
|
|
VFC Moderna 50mcg/0.5ML (12yr and older) - Covid Vaccine
|
Facility
|
OP
|
$20.83
|
|
|
Service Code
|
CPT 91322
|
| Hospital Charge Code |
6230235
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$5.83 |
| Max. Negotiated Rate |
$364.80 |
| Rate for Payer: Aetna Commercial |
$18.75
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$17.91
|
| Rate for Payer: Aetna Managed Medicare |
$5.83
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$13.54
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$10.42
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$10.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$11.04
|
| Rate for Payer: Cash Price |
$6.25
|
| Rate for Payer: Cash Price |
$6.25
|
| Rate for Payer: Cigna Commercial |
$19.16
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$193.05
|
| Rate for Payer: Health EOS Commercial |
$18.54
|
| Rate for Payer: HFN Commercial |
$19.16
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$15.62
|
| Rate for Payer: Multiplan Commercial |
$16.66
|
| Rate for Payer: NAPHCARE Commercial |
$12.50
|
| Rate for Payer: Preferred Network Access Commercial |
$19.16
|
| Rate for Payer: Quartz Beloit One Network |
$10.21
|
| Rate for Payer: Quartz Commercial |
$13.54
|
| Rate for Payer: Quartz Medicare Advantage |
$12.50
|
| Rate for Payer: The Alliance Commercial |
$83.32
|
| Rate for Payer: WEA Trust Commercial |
$11.46
|
| Rate for Payer: WPS Commercial |
$364.80
|
|
|
VFC Moderna 50mcg/0.5ML (12yr and older) - Covid Vaccine
|
Professional
|
Both
|
$20.83
|
|
|
Service Code
|
CPT 91322
|
| Hospital Charge Code |
6230235
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$9.17 |
| Max. Negotiated Rate |
$364.80 |
| Rate for Payer: Aetna Commercial |
$19.79
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$17.91
|
| Rate for Payer: Cash Price |
$6.25
|
| Rate for Payer: Cash Price |
$6.25
|
| Rate for Payer: Cigna Commercial |
$19.79
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$145.92
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$145.92
|
| Rate for Payer: Health EOS Commercial |
$18.96
|
| Rate for Payer: HFN Commercial |
$19.79
|
| Rate for Payer: Multiplan Commercial |
$16.66
|
| Rate for Payer: Preferred Network Access Commercial |
$19.79
|
| Rate for Payer: Quartz Beloit One Network |
$9.17
|
| Rate for Payer: Quartz Commercial |
$11.87
|
| Rate for Payer: The Alliance Commercial |
$10.42
|
| Rate for Payer: United Healthcare Medicaid |
$145.92
|
| Rate for Payer: WEA Trust Commercial |
$11.46
|
| Rate for Payer: WPS Commercial |
$364.80
|
|
|
VFC Moderna 50mcg/0.5ML (12yr and older) - Covid Vaccine
|
Facility
|
IP
|
$20.83
|
|
|
Service Code
|
CPT 91322
|
| Hospital Charge Code |
6230235
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$10.21 |
| Max. Negotiated Rate |
$19.16 |
| Rate for Payer: Aetna Commercial |
$18.75
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$17.91
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$11.04
|
| Rate for Payer: Cash Price |
$6.25
|
| Rate for Payer: Cigna Commercial |
$19.16
|
| Rate for Payer: Health EOS Commercial |
$18.54
|
| Rate for Payer: HFN Commercial |
$19.16
|
| Rate for Payer: Multiplan Commercial |
$16.66
|
| Rate for Payer: NAPHCARE Commercial |
$12.50
|
| Rate for Payer: Preferred Network Access Commercial |
$19.16
|
| Rate for Payer: Quartz Beloit One Network |
$10.21
|
| Rate for Payer: Quartz Commercial |
$12.50
|
| Rate for Payer: WEA Trust Commercial |
$11.46
|
| Rate for Payer: WPS Commercial |
$15.43
|
|
|
VHZ Ag / 3650
|
Facility
|
IP
|
$163.00
|
|
|
Service Code
|
CPT 87290
|
| Hospital Charge Code |
3256242
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$79.87 |
| Max. Negotiated Rate |
$149.96 |
| Rate for Payer: Aetna Commercial |
$146.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$140.18
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$86.39
|
| Rate for Payer: Cash Price |
$48.90
|
| Rate for Payer: Cigna Commercial |
$149.96
|
| Rate for Payer: Health EOS Commercial |
$145.07
|
| Rate for Payer: HFN Commercial |
$149.96
|
| Rate for Payer: Multiplan Commercial |
$130.40
|
| Rate for Payer: NAPHCARE Commercial |
$97.80
|
| Rate for Payer: Preferred Network Access Commercial |
$149.96
|
| Rate for Payer: Quartz Beloit One Network |
$79.87
|
| Rate for Payer: Quartz Commercial |
$97.80
|
| Rate for Payer: WEA Trust Commercial |
$89.65
|
| Rate for Payer: WPS Commercial |
$120.73
|
|
|
VHZ Ag / 3650
|
Professional
|
Both
|
$163.00
|
|
|
Service Code
|
CPT 87290
|
| Hospital Charge Code |
3256242
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$47.37 |
| Max. Negotiated Rate |
$154.85 |
| Rate for Payer: Aetna Commercial |
$154.85
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$140.18
|
| Rate for Payer: Cash Price |
$48.90
|
| Rate for Payer: Cash Price |
$48.90
|
| Rate for Payer: Cigna Commercial |
$154.85
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$81.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$97.80
|
| Rate for Payer: Health EOS Commercial |
$148.33
|
| Rate for Payer: HFN Commercial |
$154.85
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$47.37
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$47.37
|
| Rate for Payer: Multiplan Commercial |
$130.40
|
| Rate for Payer: Preferred Network Access Commercial |
$154.85
|
| Rate for Payer: Quartz Beloit One Network |
$71.72
|
| Rate for Payer: Quartz Commercial |
$92.91
|
| Rate for Payer: The Alliance Commercial |
$81.50
|
| Rate for Payer: WEA Trust Commercial |
$89.65
|
| Rate for Payer: WPS Commercial |
$120.73
|
|
|
VHZ Ag / 3650
|
Facility
|
OP
|
$163.00
|
|
|
Service Code
|
CPT 87290
|
| Hospital Charge Code |
3256242
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$13.42 |
| Max. Negotiated Rate |
$149.96 |
| Rate for Payer: Aetna Commercial |
$146.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$140.18
|
| Rate for Payer: Aetna Managed Medicare |
$13.42
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$50.32
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$23.48
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$22.28
|
| Rate for Payer: Anthem Medicaid |
$13.87
|
| Rate for Payer: Anthem Medicare Advantage |
$13.42
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$86.39
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$13.42
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$13.42
|
| Rate for Payer: Cash Price |
$48.90
|
| Rate for Payer: Cash Price |
$48.90
|
| Rate for Payer: Cigna Commercial |
$149.96
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$13.42
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$13.87
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$91.21
|
| Rate for Payer: Dean Health Medicaid |
$13.87
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$13.42
|
| Rate for Payer: Health EOS Commercial |
$145.07
|
| Rate for Payer: HFN Commercial |
$149.96
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$49.92
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$13.42
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$13.87
|
| Rate for Payer: Independent Care Health Plan Medicare |
$13.42
|
| Rate for Payer: Managed Health Services Medicaid |
$14.42
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$13.42
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$13.42
|
| Rate for Payer: Multiplan Commercial |
$130.40
|
| Rate for Payer: NAPHCARE Commercial |
$20.13
|
| Rate for Payer: Preferred Network Access Commercial |
$149.96
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$13.87
|
| Rate for Payer: Quartz Beloit One Network |
$79.87
|
| Rate for Payer: Quartz Commercial |
$105.95
|
| Rate for Payer: Quartz Medicare Advantage |
$13.42
|
| Rate for Payer: The Alliance Commercial |
$53.68
|
| Rate for Payer: United Healthcare Medicaid |
$13.87
|
| Rate for Payer: United Healthcare Medicare Advantage |
$13.42
|
| Rate for Payer: United Healthcare PPO |
$122.25
|
| Rate for Payer: WEA Trust Commercial |
$89.65
|
| Rate for Payer: Wellcare Medicare |
$13.42
|
| Rate for Payer: WMAP Medicaid |
$13.87
|
| Rate for Payer: WPS Commercial |
$120.73
|
|
|
Viabahn 5mm x 10cm
|
Facility
|
IP
|
$14,663.00
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
2549068
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$7,184.87 |
| Max. Negotiated Rate |
$13,489.96 |
| Rate for Payer: Aetna Commercial |
$13,196.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$12,610.18
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$7,771.39
|
| Rate for Payer: Cash Price |
$4,398.90
|
| Rate for Payer: Cigna Commercial |
$13,489.96
|
| Rate for Payer: Health EOS Commercial |
$13,050.07
|
| Rate for Payer: HFN Commercial |
$13,489.96
|
| Rate for Payer: Multiplan Commercial |
$11,730.40
|
| Rate for Payer: NAPHCARE Commercial |
$8,797.80
|
| Rate for Payer: Preferred Network Access Commercial |
$13,489.96
|
| Rate for Payer: Quartz Beloit One Network |
$7,184.87
|
| Rate for Payer: Quartz Commercial |
$8,797.80
|
| Rate for Payer: WEA Trust Commercial |
$8,064.65
|
| Rate for Payer: WPS Commercial |
$10,860.88
|
|
|
Viabahn 5mm x 10cm
|
Facility
|
OP
|
$14,663.00
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
2549068
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,105.64 |
| Max. Negotiated Rate |
$58,652.00 |
| Rate for Payer: Aetna Commercial |
$13,196.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$12,610.18
|
| Rate for Payer: Aetna Managed Medicare |
$4,105.64
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$9,530.95
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$7,331.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$7,038.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$7,771.39
|
| Rate for Payer: Cash Price |
$4,398.90
|
| Rate for Payer: Cigna Commercial |
$13,489.96
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$8,205.41
|
| Rate for Payer: Health EOS Commercial |
$13,050.07
|
| Rate for Payer: HFN Commercial |
$13,489.96
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$10,997.25
|
| Rate for Payer: Multiplan Commercial |
$11,730.40
|
| Rate for Payer: NAPHCARE Commercial |
$8,797.80
|
| Rate for Payer: Preferred Network Access Commercial |
$13,489.96
|
| Rate for Payer: Quartz Beloit One Network |
$7,184.87
|
| Rate for Payer: Quartz Commercial |
$9,530.95
|
| Rate for Payer: Quartz Medicare Advantage |
$8,797.80
|
| Rate for Payer: The Alliance Commercial |
$58,652.00
|
| Rate for Payer: WEA Trust Commercial |
$8,064.65
|
| Rate for Payer: WPS Commercial |
$10,860.88
|
|
|
Viabahn 5mm x 10cm
|
Professional
|
Both
|
$14,663.00
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
2549068
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6,451.72 |
| Max. Negotiated Rate |
$13,929.85 |
| Rate for Payer: Aetna Commercial |
$13,929.85
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$12,610.18
|
| Rate for Payer: Cash Price |
$4,398.90
|
| Rate for Payer: Cigna Commercial |
$13,929.85
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$7,331.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$8,797.80
|
| Rate for Payer: Health EOS Commercial |
$13,343.33
|
| Rate for Payer: HFN Commercial |
$13,929.85
|
| Rate for Payer: Multiplan Commercial |
$11,730.40
|
| Rate for Payer: Preferred Network Access Commercial |
$13,929.85
|
| Rate for Payer: Quartz Beloit One Network |
$6,451.72
|
| Rate for Payer: Quartz Commercial |
$8,357.91
|
| Rate for Payer: The Alliance Commercial |
$7,331.50
|
| Rate for Payer: WEA Trust Commercial |
$8,064.65
|
| Rate for Payer: WPS Commercial |
$10,860.88
|
|
|
VIABAHN 5MM X 10CM #VBJ051002
|
Facility
|
IP
|
$19,495.00
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
2973932
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$9,552.55 |
| Max. Negotiated Rate |
$17,935.40 |
| Rate for Payer: Aetna Commercial |
$17,545.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$16,765.70
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$10,332.35
|
| Rate for Payer: Cash Price |
$5,848.50
|
| Rate for Payer: Cigna Commercial |
$17,935.40
|
| Rate for Payer: Health EOS Commercial |
$17,350.55
|
| Rate for Payer: HFN Commercial |
$17,935.40
|
| Rate for Payer: Multiplan Commercial |
$15,596.00
|
| Rate for Payer: NAPHCARE Commercial |
$11,697.00
|
| Rate for Payer: Preferred Network Access Commercial |
$17,935.40
|
| Rate for Payer: Quartz Beloit One Network |
$9,552.55
|
| Rate for Payer: Quartz Commercial |
$11,697.00
|
| Rate for Payer: WEA Trust Commercial |
$10,722.25
|
| Rate for Payer: WPS Commercial |
$14,439.95
|
|
