|
VHZ Ag / 3650
|
Professional
|
$163.00
|
|
|
Service Code
|
CPT 87290
|
| Hospital Charge Code |
3256242
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$13.42 |
| Max. Negotiated Rate |
$154.85 |
| Rate for Payer: Aetna Commercial |
$154.85
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$140.18
|
| Rate for Payer: Aetna Managed Medicare |
$13.42
|
| Rate for Payer: Anthem Medicare Advantage |
$13.42
|
| 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 |
$154.85
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$81.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$13.42
|
| Rate for Payer: Health EOS Commercial |
$148.33
|
| 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: Independent Care Health Plan Medicare |
$13.42
|
| 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: Quartz Medicare Advantage |
$13.42
|
| Rate for Payer: The Alliance Commercial |
$53.01
|
| Rate for Payer: United Healthcare Medicare Advantage |
$13.42
|
| Rate for Payer: WEA Trust Commercial |
$89.65
|
| Rate for Payer: WPS Commercial |
$59.05
|
|
|
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 |
$652.00 |
| 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 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 |
$652.00
|
| 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
|
|
|
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: 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
|
|
|
Viabahn 5mm x 10cm
|
Professional
|
$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: 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
|
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: 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 |
$13,489.96 |
| 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: 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: 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
|
|
|
VIABAHN 5MM X 10CM #VBJ051002
|
Facility
OP
|
$19,495.00
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
2973932
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,458.60 |
| 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: Aetna Managed Medicare |
$5,458.60
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$12,671.75
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$9,747.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$9,357.60
|
| 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: Dean Health DHI/DHP/ASO |
$10,909.40
|
| Rate for Payer: Health EOS Commercial |
$17,350.55
|
| Rate for Payer: HFN Commercial |
$17,935.40
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$14,621.25
|
| 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 |
$12,671.75
|
| Rate for Payer: Quartz Medicare Advantage |
$11,697.00
|
| Rate for Payer: WEA Trust Commercial |
$10,722.25
|
| Rate for Payer: WPS Commercial |
$14,439.95
|
|
|
Viabahn 5mm x 15cm
|
Professional
|
$14,663.00
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
2549070
|
|
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: 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 15cm
|
Facility
IP
|
$14,663.00
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
2549070
|
|
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: 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 15cm
|
Facility
OP
|
$14,663.00
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
2549070
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,105.64 |
| 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: 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: WEA Trust Commercial |
$8,064.65
|
| Rate for Payer: WPS Commercial |
$10,860.88
|
|
|
VIABAHN 5MM X 15CM #372611
|
Facility
IP
|
$23,577.00
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
2973933
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$11,552.73 |
| Max. Negotiated Rate |
$21,690.84 |
| Rate for Payer: Aetna Commercial |
$21,219.30
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$12,495.81
|
| Rate for Payer: Cash Price |
$7,073.10
|
| Rate for Payer: Cigna Commercial |
$21,690.84
|
| Rate for Payer: Health EOS Commercial |
$20,983.53
|
| Rate for Payer: HFN Commercial |
$21,690.84
|
| Rate for Payer: Multiplan Commercial |
$18,861.60
|
| Rate for Payer: NAPHCARE Commercial |
$14,146.20
|
| Rate for Payer: Preferred Network Access Commercial |
$21,690.84
|
| Rate for Payer: Quartz Beloit One Network |
$11,552.73
|
| Rate for Payer: Quartz Commercial |
$14,146.20
|
| Rate for Payer: WEA Trust Commercial |
$12,967.35
|
| Rate for Payer: WPS Commercial |
$17,463.48
|
|
|
VIABAHN 5MM X 15CM #372611
|
Facility
OP
|
$23,577.00
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
2973933
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6,601.56 |
| Max. Negotiated Rate |
$21,690.84 |
| Rate for Payer: Aetna Commercial |
$21,219.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$20,276.22
|
| Rate for Payer: Aetna Managed Medicare |
$6,601.56
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$15,325.05
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$11,788.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$11,316.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$12,495.81
|
| Rate for Payer: Cash Price |
$7,073.10
|
| Rate for Payer: Cigna Commercial |
$21,690.84
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$13,193.69
|
| Rate for Payer: Health EOS Commercial |
$20,983.53
|
| Rate for Payer: HFN Commercial |
$21,690.84
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$17,682.75
|
| Rate for Payer: Multiplan Commercial |
$18,861.60
|
| Rate for Payer: NAPHCARE Commercial |
$14,146.20
|
| Rate for Payer: Preferred Network Access Commercial |
$21,690.84
|
| Rate for Payer: Quartz Beloit One Network |
$11,552.73
|
| Rate for Payer: Quartz Commercial |
$15,325.05
|
| Rate for Payer: Quartz Medicare Advantage |
$14,146.20
|
| Rate for Payer: WEA Trust Commercial |
$12,967.35
|
| Rate for Payer: WPS Commercial |
$17,463.48
|
|
|
Viabahn 5mm x 5cm
|
Professional
|
$14,663.00
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
2549066
|
|
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: 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 5cm
|
Facility
OP
|
$14,663.00
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
2549066
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,105.64 |
| 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: 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: WEA Trust Commercial |
$8,064.65
|
| Rate for Payer: WPS Commercial |
$10,860.88
|
|
|
Viabahn 5mm x 5cm
|
Facility
IP
|
$14,663.00
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
2549066
|
|
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: 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 6mm x 10cm
|
Facility
IP
|
$14,663.00
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
2549074
|
|
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: 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 6mm x 10cm
|
Professional
|
$14,663.00
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
2549074
|
|
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: 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 6mm x 10cm
|
Facility
OP
|
$14,663.00
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
2549074
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,105.64 |
| 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: 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: WEA Trust Commercial |
$8,064.65
|
| Rate for Payer: WPS Commercial |
$10,860.88
|
|
|
VIABAHN 6MM X 10CM #VBJ061002
|
Facility
IP
|
$20,720.00
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
2973931
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$10,152.80 |
| Max. Negotiated Rate |
$19,062.40 |
| Rate for Payer: Aetna Commercial |
$18,648.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$10,981.60
|
| Rate for Payer: Cash Price |
$6,216.00
|
| Rate for Payer: Cigna Commercial |
$19,062.40
|
| Rate for Payer: Health EOS Commercial |
$18,440.80
|
| Rate for Payer: HFN Commercial |
$19,062.40
|
| Rate for Payer: Multiplan Commercial |
$16,576.00
|
| Rate for Payer: NAPHCARE Commercial |
$12,432.00
|
| Rate for Payer: Preferred Network Access Commercial |
$19,062.40
|
| Rate for Payer: Quartz Beloit One Network |
$10,152.80
|
| Rate for Payer: Quartz Commercial |
$12,432.00
|
| Rate for Payer: WEA Trust Commercial |
$11,396.00
|
| Rate for Payer: WPS Commercial |
$15,347.30
|
|
|
VIABAHN 6MM X 10CM #VBJ061002
|
Facility
OP
|
$20,720.00
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
2973931
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,801.60 |
| Max. Negotiated Rate |
$19,062.40 |
| Rate for Payer: Aetna Commercial |
$18,648.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$17,819.20
|
| Rate for Payer: Aetna Managed Medicare |
$5,801.60
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$13,468.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$10,360.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$9,945.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$10,981.60
|
| Rate for Payer: Cash Price |
$6,216.00
|
| Rate for Payer: Cigna Commercial |
$19,062.40
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$11,594.91
|
| Rate for Payer: Health EOS Commercial |
$18,440.80
|
| Rate for Payer: HFN Commercial |
$19,062.40
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$15,540.00
|
| Rate for Payer: Multiplan Commercial |
$16,576.00
|
| Rate for Payer: NAPHCARE Commercial |
$12,432.00
|
| Rate for Payer: Preferred Network Access Commercial |
$19,062.40
|
| Rate for Payer: Quartz Beloit One Network |
$10,152.80
|
| Rate for Payer: Quartz Commercial |
$13,468.00
|
| Rate for Payer: Quartz Medicare Advantage |
$12,432.00
|
| Rate for Payer: WEA Trust Commercial |
$11,396.00
|
| Rate for Payer: WPS Commercial |
$15,347.30
|
|
|
Viabahn 6mm x 15cm
|
Facility
IP
|
$14,663.00
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
2549076
|
|
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: 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 6mm x 15cm
|
Professional
|
$14,663.00
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
2549076
|
|
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: 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 6mm x 15cm
|
Facility
OP
|
$14,663.00
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
2549076
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,105.64 |
| 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: 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: WEA Trust Commercial |
$8,064.65
|
| Rate for Payer: WPS Commercial |
$10,860.88
|
|
|
Viabahn 6mm x 5cm
|
Facility
IP
|
$14,663.00
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
2549072
|
|
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: 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
|
|
