|
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 |
$6.07 |
| Max. Negotiated Rate |
$611.77 |
| Rate for Payer: Aetna Commercial |
$19.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$18.63
|
| Rate for Payer: Aetna Managed Medicare |
$6.07
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$14.08
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$10.83
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$10.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$11.48
|
| Rate for Payer: Cash Price |
$6.25
|
| Rate for Payer: Cash Price |
$6.25
|
| Rate for Payer: Cigna Commercial |
$19.93
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$200.77
|
| Rate for Payer: Health EOS Commercial |
$19.28
|
| Rate for Payer: HFN Commercial |
$19.93
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$16.25
|
| Rate for Payer: Multiplan Commercial |
$17.33
|
| Rate for Payer: NAPHCARE Commercial |
$13.00
|
| Rate for Payer: Preferred Network Access Commercial |
$19.93
|
| Rate for Payer: Quartz Beloit One Network |
$10.61
|
| Rate for Payer: Quartz Commercial |
$14.08
|
| Rate for Payer: Quartz Medicare Advantage |
$13.00
|
| Rate for Payer: The Alliance Commercial |
$611.77
|
| Rate for Payer: WEA Trust Commercial |
$11.91
|
| Rate for Payer: WPS Commercial |
$379.39
|
|
|
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 |
$9.53 |
| Max. Negotiated Rate |
$382.36 |
| Rate for Payer: Aetna Commercial |
$20.58
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$18.63
|
| Rate for Payer: Aetna Managed Medicare |
$152.94
|
| Rate for Payer: Anthem Medicare Advantage |
$152.94
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$152.94
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$152.94
|
| Rate for Payer: Cash Price |
$6.25
|
| Rate for Payer: Cash Price |
$6.25
|
| Rate for Payer: Cigna Commercial |
$20.58
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$134.16
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$151.76
|
| Rate for Payer: Health EOS Commercial |
$19.71
|
| Rate for Payer: HFN Commercial |
$20.58
|
| Rate for Payer: Independent Care Health Plan Medicare |
$152.94
|
| Rate for Payer: Multiplan Commercial |
$17.33
|
| Rate for Payer: NAPHCARE Commercial |
$229.41
|
| Rate for Payer: Preferred Network Access Commercial |
$20.58
|
| Rate for Payer: Quartz Beloit One Network |
$9.53
|
| Rate for Payer: Quartz Commercial |
$12.35
|
| Rate for Payer: Quartz Medicare Advantage |
$152.94
|
| Rate for Payer: The Alliance Commercial |
$382.36
|
| Rate for Payer: United Healthcare Medicaid |
$134.16
|
| Rate for Payer: United Healthcare Medicare Advantage |
$152.94
|
| Rate for Payer: WEA Trust Commercial |
$11.91
|
| Rate for Payer: WPS Commercial |
$379.39
|
|
|
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 |
$9.53 |
| Max. Negotiated Rate |
$420.29 |
| Rate for Payer: Aetna Commercial |
$20.58
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$18.63
|
| Rate for Payer: Aetna Managed Medicare |
$168.12
|
| Rate for Payer: Anthem Medicare Advantage |
$168.12
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$168.12
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$168.12
|
| Rate for Payer: Cash Price |
$6.25
|
| Rate for Payer: Cash Price |
$6.25
|
| Rate for Payer: Cigna Commercial |
$20.58
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$147.47
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$151.76
|
| Rate for Payer: Health EOS Commercial |
$19.71
|
| Rate for Payer: HFN Commercial |
$20.58
|
| Rate for Payer: Independent Care Health Plan Medicare |
$168.12
|
| Rate for Payer: Multiplan Commercial |
$17.33
|
| Rate for Payer: NAPHCARE Commercial |
$252.17
|
| Rate for Payer: Preferred Network Access Commercial |
$20.58
|
| Rate for Payer: Quartz Beloit One Network |
$9.53
|
| Rate for Payer: Quartz Commercial |
$12.35
|
| Rate for Payer: Quartz Medicare Advantage |
$168.12
|
| Rate for Payer: The Alliance Commercial |
$420.29
|
| Rate for Payer: United Healthcare Medicaid |
$147.47
|
| Rate for Payer: United Healthcare Medicare Advantage |
$168.12
|
| Rate for Payer: WEA Trust Commercial |
$11.91
|
| Rate for Payer: WPS Commercial |
$379.39
|
|
|
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 |
$6.07 |
| Max. Negotiated Rate |
$672.46 |
| Rate for Payer: Aetna Commercial |
$19.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$18.63
|
| Rate for Payer: Aetna Managed Medicare |
$6.07
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$14.08
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$10.83
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$10.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$11.48
|
| Rate for Payer: Cash Price |
$6.25
|
| Rate for Payer: Cash Price |
$6.25
|
| Rate for Payer: Cigna Commercial |
$19.93
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$200.77
|
| Rate for Payer: Health EOS Commercial |
$19.28
|
| Rate for Payer: HFN Commercial |
$19.93
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$16.25
|
| Rate for Payer: Multiplan Commercial |
$17.33
|
| Rate for Payer: NAPHCARE Commercial |
$13.00
|
| Rate for Payer: Preferred Network Access Commercial |
$19.93
|
| Rate for Payer: Quartz Beloit One Network |
$10.61
|
| Rate for Payer: Quartz Commercial |
$14.08
|
| Rate for Payer: Quartz Medicare Advantage |
$13.00
|
| Rate for Payer: The Alliance Commercial |
$672.46
|
| Rate for Payer: WEA Trust Commercial |
$11.91
|
| Rate for Payer: WPS Commercial |
$379.39
|
|
|
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 |
$10.61 |
| Max. Negotiated Rate |
$19.93 |
| Rate for Payer: Aetna Commercial |
$19.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$18.63
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$11.48
|
| Rate for Payer: Cash Price |
$6.25
|
| Rate for Payer: Cigna Commercial |
$19.93
|
| Rate for Payer: Health EOS Commercial |
$19.28
|
| Rate for Payer: HFN Commercial |
$19.93
|
| Rate for Payer: Multiplan Commercial |
$17.33
|
| Rate for Payer: Preferred Network Access Commercial |
$19.93
|
| Rate for Payer: Quartz Beloit One Network |
$10.61
|
| Rate for Payer: Quartz Commercial |
$13.00
|
| Rate for Payer: WEA Trust Commercial |
$11.91
|
| Rate for Payer: WPS Commercial |
$16.05
|
|
|
VHZ Ag / 3650
|
Facility
|
IP
|
$163.00
|
|
|
Service Code
|
CPT 87290
|
| Hospital Charge Code |
3256242
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$83.06 |
| Max. Negotiated Rate |
$155.96 |
| Rate for Payer: Aetna Commercial |
$152.57
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$145.79
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$89.85
|
| Rate for Payer: Cash Price |
$48.90
|
| Rate for Payer: Cigna Commercial |
$155.96
|
| Rate for Payer: Health EOS Commercial |
$150.87
|
| Rate for Payer: HFN Commercial |
$155.96
|
| Rate for Payer: Multiplan Commercial |
$135.62
|
| Rate for Payer: Preferred Network Access Commercial |
$155.96
|
| Rate for Payer: Quartz Beloit One Network |
$83.06
|
| Rate for Payer: Quartz Commercial |
$101.71
|
| Rate for Payer: WEA Trust Commercial |
$93.24
|
| Rate for Payer: WPS Commercial |
$125.56
|
|
|
VHZ Ag / 3650
|
Facility
|
OP
|
$163.00
|
|
|
Service Code
|
CPT 87290
|
| Hospital Charge Code |
3256242
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$13.96 |
| Max. Negotiated Rate |
$155.96 |
| Rate for Payer: Aetna Commercial |
$152.57
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$145.79
|
| Rate for Payer: Aetna Managed Medicare |
$13.96
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$52.34
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$24.42
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$23.17
|
| Rate for Payer: Anthem Medicare Advantage |
$13.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$89.85
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$13.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$13.96
|
| Rate for Payer: Cash Price |
$48.90
|
| Rate for Payer: Cash Price |
$48.90
|
| Rate for Payer: Cigna Commercial |
$155.96
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$13.96
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$94.87
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$13.96
|
| Rate for Payer: Health EOS Commercial |
$150.87
|
| Rate for Payer: HFN Commercial |
$155.96
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$51.92
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$13.96
|
| Rate for Payer: Independent Care Health Plan Medicare |
$13.96
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$13.96
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$13.96
|
| Rate for Payer: Multiplan Commercial |
$135.62
|
| Rate for Payer: NAPHCARE Commercial |
$20.94
|
| Rate for Payer: Preferred Network Access Commercial |
$155.96
|
| Rate for Payer: Quartz Beloit One Network |
$83.06
|
| Rate for Payer: Quartz Commercial |
$110.19
|
| Rate for Payer: Quartz Medicare Advantage |
$13.96
|
| Rate for Payer: The Alliance Commercial |
$55.83
|
| Rate for Payer: United Healthcare Medicare Advantage |
$13.96
|
| Rate for Payer: United Healthcare PPO |
$127.14
|
| Rate for Payer: WEA Trust Commercial |
$93.24
|
| Rate for Payer: Wellcare Medicare |
$13.96
|
| Rate for Payer: WPS Commercial |
$125.56
|
|
|
VHZ Ag / 3650
|
Professional
|
Both
|
$163.00
|
|
|
Service Code
|
CPT 87290
|
| Hospital Charge Code |
3256242
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$13.96 |
| Max. Negotiated Rate |
$161.04 |
| Rate for Payer: Aetna Commercial |
$161.04
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$145.79
|
| Rate for Payer: Aetna Managed Medicare |
$13.96
|
| Rate for Payer: Anthem Medicare Advantage |
$13.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$13.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$13.96
|
| Rate for Payer: Cash Price |
$48.90
|
| Rate for Payer: Cash Price |
$48.90
|
| Rate for Payer: Cigna Commercial |
$161.04
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$84.76
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$13.96
|
| Rate for Payer: Health EOS Commercial |
$154.26
|
| Rate for Payer: HFN Commercial |
$161.04
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$49.26
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$49.26
|
| Rate for Payer: Independent Care Health Plan Medicare |
$13.96
|
| Rate for Payer: Multiplan Commercial |
$135.62
|
| Rate for Payer: NAPHCARE Commercial |
$20.94
|
| Rate for Payer: Preferred Network Access Commercial |
$161.04
|
| Rate for Payer: Quartz Beloit One Network |
$74.59
|
| Rate for Payer: Quartz Commercial |
$96.63
|
| Rate for Payer: Quartz Medicare Advantage |
$13.96
|
| Rate for Payer: The Alliance Commercial |
$55.13
|
| Rate for Payer: United Healthcare Medicare Advantage |
$13.96
|
| Rate for Payer: WEA Trust Commercial |
$93.24
|
| Rate for Payer: WPS Commercial |
$61.41
|
|
|
Viabahn 5mm x 10cm
|
Facility
|
IP
|
$14,663.00
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
2549068
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$7,472.26 |
| Max. Negotiated Rate |
$14,029.56 |
| Rate for Payer: Aetna Commercial |
$13,724.57
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$13,114.59
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$8,082.25
|
| Rate for Payer: Cash Price |
$4,398.90
|
| Rate for Payer: Cigna Commercial |
$14,029.56
|
| Rate for Payer: Health EOS Commercial |
$13,572.07
|
| Rate for Payer: HFN Commercial |
$14,029.56
|
| Rate for Payer: Multiplan Commercial |
$12,199.62
|
| Rate for Payer: Preferred Network Access Commercial |
$14,029.56
|
| Rate for Payer: Quartz Beloit One Network |
$7,472.26
|
| Rate for Payer: Quartz Commercial |
$9,149.71
|
| Rate for Payer: WEA Trust Commercial |
$8,387.24
|
| Rate for Payer: WPS Commercial |
$11,294.91
|
|
|
Viabahn 5mm x 10cm
|
Facility
|
OP
|
$14,663.00
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
2549068
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,269.87 |
| Max. Negotiated Rate |
$14,029.56 |
| Rate for Payer: Aetna Commercial |
$13,724.57
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$13,114.59
|
| Rate for Payer: Aetna Managed Medicare |
$4,269.87
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$9,912.19
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$7,624.76
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$7,319.77
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$8,082.25
|
| Rate for Payer: Cash Price |
$4,398.90
|
| Rate for Payer: Cigna Commercial |
$14,029.56
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$8,533.87
|
| Rate for Payer: Health EOS Commercial |
$13,572.07
|
| Rate for Payer: HFN Commercial |
$14,029.56
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$11,437.14
|
| Rate for Payer: Multiplan Commercial |
$12,199.62
|
| Rate for Payer: NAPHCARE Commercial |
$9,149.71
|
| Rate for Payer: Preferred Network Access Commercial |
$14,029.56
|
| Rate for Payer: Quartz Beloit One Network |
$7,472.26
|
| Rate for Payer: Quartz Commercial |
$9,912.19
|
| Rate for Payer: Quartz Medicare Advantage |
$9,149.71
|
| Rate for Payer: The Alliance Commercial |
$7,624.76
|
| Rate for Payer: WEA Trust Commercial |
$8,387.24
|
| Rate for Payer: WPS Commercial |
$11,294.91
|
|
|
Viabahn 5mm x 10cm
|
Professional
|
Both
|
$14,663.00
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
2549068
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6,709.79 |
| Max. Negotiated Rate |
$14,487.04 |
| Rate for Payer: Aetna Commercial |
$14,487.04
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$13,114.59
|
| Rate for Payer: Cash Price |
$4,398.90
|
| Rate for Payer: Cigna Commercial |
$14,487.04
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$7,624.76
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$9,149.71
|
| Rate for Payer: Health EOS Commercial |
$13,877.06
|
| Rate for Payer: HFN Commercial |
$14,487.04
|
| Rate for Payer: Multiplan Commercial |
$12,199.62
|
| Rate for Payer: Preferred Network Access Commercial |
$14,487.04
|
| Rate for Payer: Quartz Beloit One Network |
$6,709.79
|
| Rate for Payer: Quartz Commercial |
$8,692.23
|
| Rate for Payer: The Alliance Commercial |
$7,624.76
|
| Rate for Payer: WEA Trust Commercial |
$8,387.24
|
| Rate for Payer: WPS Commercial |
$11,294.91
|
|
|
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 |
$5,676.94 |
| Max. Negotiated Rate |
$18,652.82 |
| Rate for Payer: Aetna Commercial |
$18,247.32
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$17,436.33
|
| Rate for Payer: Aetna Managed Medicare |
$5,676.94
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$13,178.62
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$10,137.40
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$9,731.90
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$10,745.64
|
| Rate for Payer: Cash Price |
$5,848.50
|
| Rate for Payer: Cigna Commercial |
$18,652.82
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$11,346.09
|
| Rate for Payer: Health EOS Commercial |
$18,044.57
|
| Rate for Payer: HFN Commercial |
$18,652.82
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$15,206.10
|
| Rate for Payer: Multiplan Commercial |
$16,219.84
|
| Rate for Payer: NAPHCARE Commercial |
$12,164.88
|
| Rate for Payer: Preferred Network Access Commercial |
$18,652.82
|
| Rate for Payer: Quartz Beloit One Network |
$9,934.65
|
| Rate for Payer: Quartz Commercial |
$13,178.62
|
| Rate for Payer: Quartz Medicare Advantage |
$12,164.88
|
| Rate for Payer: The Alliance Commercial |
$10,137.40
|
| Rate for Payer: WEA Trust Commercial |
$11,151.14
|
| Rate for Payer: WPS Commercial |
$15,017.00
|
|
|
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 |
$9,934.65 |
| Max. Negotiated Rate |
$18,652.82 |
| Rate for Payer: Aetna Commercial |
$18,247.32
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$17,436.33
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$10,745.64
|
| Rate for Payer: Cash Price |
$5,848.50
|
| Rate for Payer: Cigna Commercial |
$18,652.82
|
| Rate for Payer: Health EOS Commercial |
$18,044.57
|
| Rate for Payer: HFN Commercial |
$18,652.82
|
| Rate for Payer: Multiplan Commercial |
$16,219.84
|
| Rate for Payer: Preferred Network Access Commercial |
$18,652.82
|
| Rate for Payer: Quartz Beloit One Network |
$9,934.65
|
| Rate for Payer: Quartz Commercial |
$12,164.88
|
| Rate for Payer: WEA Trust Commercial |
$11,151.14
|
| Rate for Payer: WPS Commercial |
$15,017.00
|
|
|
Viabahn 5mm x 15cm
|
Facility
|
OP
|
$14,663.00
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
2549070
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,269.87 |
| Max. Negotiated Rate |
$14,029.56 |
| Rate for Payer: Aetna Commercial |
$13,724.57
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$13,114.59
|
| Rate for Payer: Aetna Managed Medicare |
$4,269.87
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$9,912.19
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$7,624.76
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$7,319.77
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$8,082.25
|
| Rate for Payer: Cash Price |
$4,398.90
|
| Rate for Payer: Cigna Commercial |
$14,029.56
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$8,533.87
|
| Rate for Payer: Health EOS Commercial |
$13,572.07
|
| Rate for Payer: HFN Commercial |
$14,029.56
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$11,437.14
|
| Rate for Payer: Multiplan Commercial |
$12,199.62
|
| Rate for Payer: NAPHCARE Commercial |
$9,149.71
|
| Rate for Payer: Preferred Network Access Commercial |
$14,029.56
|
| Rate for Payer: Quartz Beloit One Network |
$7,472.26
|
| Rate for Payer: Quartz Commercial |
$9,912.19
|
| Rate for Payer: Quartz Medicare Advantage |
$9,149.71
|
| Rate for Payer: The Alliance Commercial |
$7,624.76
|
| Rate for Payer: WEA Trust Commercial |
$8,387.24
|
| Rate for Payer: WPS Commercial |
$11,294.91
|
|
|
Viabahn 5mm x 15cm
|
Facility
|
IP
|
$14,663.00
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
2549070
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$7,472.26 |
| Max. Negotiated Rate |
$14,029.56 |
| Rate for Payer: Aetna Commercial |
$13,724.57
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$13,114.59
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$8,082.25
|
| Rate for Payer: Cash Price |
$4,398.90
|
| Rate for Payer: Cigna Commercial |
$14,029.56
|
| Rate for Payer: Health EOS Commercial |
$13,572.07
|
| Rate for Payer: HFN Commercial |
$14,029.56
|
| Rate for Payer: Multiplan Commercial |
$12,199.62
|
| Rate for Payer: Preferred Network Access Commercial |
$14,029.56
|
| Rate for Payer: Quartz Beloit One Network |
$7,472.26
|
| Rate for Payer: Quartz Commercial |
$9,149.71
|
| Rate for Payer: WEA Trust Commercial |
$8,387.24
|
| Rate for Payer: WPS Commercial |
$11,294.91
|
|
|
Viabahn 5mm x 15cm
|
Professional
|
Both
|
$14,663.00
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
2549070
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6,709.79 |
| Max. Negotiated Rate |
$14,487.04 |
| Rate for Payer: Aetna Commercial |
$14,487.04
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$13,114.59
|
| Rate for Payer: Cash Price |
$4,398.90
|
| Rate for Payer: Cigna Commercial |
$14,487.04
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$7,624.76
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$9,149.71
|
| Rate for Payer: Health EOS Commercial |
$13,877.06
|
| Rate for Payer: HFN Commercial |
$14,487.04
|
| Rate for Payer: Multiplan Commercial |
$12,199.62
|
| Rate for Payer: Preferred Network Access Commercial |
$14,487.04
|
| Rate for Payer: Quartz Beloit One Network |
$6,709.79
|
| Rate for Payer: Quartz Commercial |
$8,692.23
|
| Rate for Payer: The Alliance Commercial |
$7,624.76
|
| Rate for Payer: WEA Trust Commercial |
$8,387.24
|
| Rate for Payer: WPS Commercial |
$11,294.91
|
|
|
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 |
$6,865.62 |
| Max. Negotiated Rate |
$22,558.47 |
| Rate for Payer: Aetna Commercial |
$22,068.07
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$21,087.27
|
| Rate for Payer: Aetna Managed Medicare |
$6,865.62
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$15,938.05
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$12,260.04
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$11,769.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$12,995.64
|
| Rate for Payer: Cash Price |
$7,073.10
|
| Rate for Payer: Cigna Commercial |
$22,558.47
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$13,721.81
|
| Rate for Payer: Health EOS Commercial |
$21,822.87
|
| Rate for Payer: HFN Commercial |
$22,558.47
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$18,390.06
|
| Rate for Payer: Multiplan Commercial |
$19,616.06
|
| Rate for Payer: NAPHCARE Commercial |
$14,712.05
|
| Rate for Payer: Preferred Network Access Commercial |
$22,558.47
|
| Rate for Payer: Quartz Beloit One Network |
$12,014.84
|
| Rate for Payer: Quartz Commercial |
$15,938.05
|
| Rate for Payer: Quartz Medicare Advantage |
$14,712.05
|
| Rate for Payer: The Alliance Commercial |
$12,260.04
|
| Rate for Payer: WEA Trust Commercial |
$13,486.04
|
| Rate for Payer: WPS Commercial |
$18,161.36
|
|
|
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 |
$12,014.84 |
| Max. Negotiated Rate |
$22,558.47 |
| Rate for Payer: Aetna Commercial |
$22,068.07
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$21,087.27
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$12,995.64
|
| Rate for Payer: Cash Price |
$7,073.10
|
| Rate for Payer: Cigna Commercial |
$22,558.47
|
| Rate for Payer: Health EOS Commercial |
$21,822.87
|
| Rate for Payer: HFN Commercial |
$22,558.47
|
| Rate for Payer: Multiplan Commercial |
$19,616.06
|
| Rate for Payer: Preferred Network Access Commercial |
$22,558.47
|
| Rate for Payer: Quartz Beloit One Network |
$12,014.84
|
| Rate for Payer: Quartz Commercial |
$14,712.05
|
| Rate for Payer: WEA Trust Commercial |
$13,486.04
|
| Rate for Payer: WPS Commercial |
$18,161.36
|
|
|
Viabahn 5mm x 5cm
|
Facility
|
IP
|
$14,663.00
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
2549066
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$7,472.26 |
| Max. Negotiated Rate |
$14,029.56 |
| Rate for Payer: Aetna Commercial |
$13,724.57
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$13,114.59
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$8,082.25
|
| Rate for Payer: Cash Price |
$4,398.90
|
| Rate for Payer: Cigna Commercial |
$14,029.56
|
| Rate for Payer: Health EOS Commercial |
$13,572.07
|
| Rate for Payer: HFN Commercial |
$14,029.56
|
| Rate for Payer: Multiplan Commercial |
$12,199.62
|
| Rate for Payer: Preferred Network Access Commercial |
$14,029.56
|
| Rate for Payer: Quartz Beloit One Network |
$7,472.26
|
| Rate for Payer: Quartz Commercial |
$9,149.71
|
| Rate for Payer: WEA Trust Commercial |
$8,387.24
|
| Rate for Payer: WPS Commercial |
$11,294.91
|
|
|
Viabahn 5mm x 5cm
|
Facility
|
OP
|
$14,663.00
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
2549066
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,269.87 |
| Max. Negotiated Rate |
$14,029.56 |
| Rate for Payer: Aetna Commercial |
$13,724.57
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$13,114.59
|
| Rate for Payer: Aetna Managed Medicare |
$4,269.87
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$9,912.19
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$7,624.76
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$7,319.77
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$8,082.25
|
| Rate for Payer: Cash Price |
$4,398.90
|
| Rate for Payer: Cigna Commercial |
$14,029.56
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$8,533.87
|
| Rate for Payer: Health EOS Commercial |
$13,572.07
|
| Rate for Payer: HFN Commercial |
$14,029.56
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$11,437.14
|
| Rate for Payer: Multiplan Commercial |
$12,199.62
|
| Rate for Payer: NAPHCARE Commercial |
$9,149.71
|
| Rate for Payer: Preferred Network Access Commercial |
$14,029.56
|
| Rate for Payer: Quartz Beloit One Network |
$7,472.26
|
| Rate for Payer: Quartz Commercial |
$9,912.19
|
| Rate for Payer: Quartz Medicare Advantage |
$9,149.71
|
| Rate for Payer: The Alliance Commercial |
$7,624.76
|
| Rate for Payer: WEA Trust Commercial |
$8,387.24
|
| Rate for Payer: WPS Commercial |
$11,294.91
|
|
|
Viabahn 5mm x 5cm
|
Professional
|
Both
|
$14,663.00
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
2549066
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6,709.79 |
| Max. Negotiated Rate |
$14,487.04 |
| Rate for Payer: Aetna Commercial |
$14,487.04
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$13,114.59
|
| Rate for Payer: Cash Price |
$4,398.90
|
| Rate for Payer: Cigna Commercial |
$14,487.04
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$7,624.76
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$9,149.71
|
| Rate for Payer: Health EOS Commercial |
$13,877.06
|
| Rate for Payer: HFN Commercial |
$14,487.04
|
| Rate for Payer: Multiplan Commercial |
$12,199.62
|
| Rate for Payer: Preferred Network Access Commercial |
$14,487.04
|
| Rate for Payer: Quartz Beloit One Network |
$6,709.79
|
| Rate for Payer: Quartz Commercial |
$8,692.23
|
| Rate for Payer: The Alliance Commercial |
$7,624.76
|
| Rate for Payer: WEA Trust Commercial |
$8,387.24
|
| Rate for Payer: WPS Commercial |
$11,294.91
|
|
|
VIABAHN 5mm x 5cm #VBJ050502
|
Facility
|
OP
|
$17,054.00
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
2973928
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,966.12 |
| Max. Negotiated Rate |
$16,317.27 |
| Rate for Payer: Aetna Commercial |
$15,962.54
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$15,253.10
|
| Rate for Payer: Aetna Managed Medicare |
$4,966.12
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$11,528.50
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$8,868.08
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$8,513.36
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$9,400.16
|
| Rate for Payer: Cash Price |
$5,116.20
|
| Rate for Payer: Cigna Commercial |
$16,317.27
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$9,925.43
|
| Rate for Payer: Health EOS Commercial |
$15,785.18
|
| Rate for Payer: HFN Commercial |
$16,317.27
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$13,302.12
|
| Rate for Payer: Multiplan Commercial |
$14,188.93
|
| Rate for Payer: NAPHCARE Commercial |
$10,641.70
|
| Rate for Payer: Preferred Network Access Commercial |
$16,317.27
|
| Rate for Payer: Quartz Beloit One Network |
$8,690.72
|
| Rate for Payer: Quartz Commercial |
$11,528.50
|
| Rate for Payer: Quartz Medicare Advantage |
$10,641.70
|
| Rate for Payer: The Alliance Commercial |
$8,868.08
|
| Rate for Payer: WEA Trust Commercial |
$9,754.89
|
| Rate for Payer: WPS Commercial |
$13,136.70
|
|
|
VIABAHN 5mm x 5cm #VBJ050502
|
Facility
|
IP
|
$17,054.00
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
2973928
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$8,690.72 |
| Max. Negotiated Rate |
$16,317.27 |
| Rate for Payer: Aetna Commercial |
$15,962.54
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$15,253.10
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$9,400.16
|
| Rate for Payer: Cash Price |
$5,116.20
|
| Rate for Payer: Cigna Commercial |
$16,317.27
|
| Rate for Payer: Health EOS Commercial |
$15,785.18
|
| Rate for Payer: HFN Commercial |
$16,317.27
|
| Rate for Payer: Multiplan Commercial |
$14,188.93
|
| Rate for Payer: Preferred Network Access Commercial |
$16,317.27
|
| Rate for Payer: Quartz Beloit One Network |
$8,690.72
|
| Rate for Payer: Quartz Commercial |
$10,641.70
|
| Rate for Payer: WEA Trust Commercial |
$9,754.89
|
| Rate for Payer: WPS Commercial |
$13,136.70
|
|
|
Viabahn 6mm x 10cm
|
Facility
|
IP
|
$14,663.00
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
2549074
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$7,472.26 |
| Max. Negotiated Rate |
$14,029.56 |
| Rate for Payer: Aetna Commercial |
$13,724.57
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$13,114.59
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$8,082.25
|
| Rate for Payer: Cash Price |
$4,398.90
|
| Rate for Payer: Cigna Commercial |
$14,029.56
|
| Rate for Payer: Health EOS Commercial |
$13,572.07
|
| Rate for Payer: HFN Commercial |
$14,029.56
|
| Rate for Payer: Multiplan Commercial |
$12,199.62
|
| Rate for Payer: Preferred Network Access Commercial |
$14,029.56
|
| Rate for Payer: Quartz Beloit One Network |
$7,472.26
|
| Rate for Payer: Quartz Commercial |
$9,149.71
|
| Rate for Payer: WEA Trust Commercial |
$8,387.24
|
| Rate for Payer: WPS Commercial |
$11,294.91
|
|
|
Viabahn 6mm x 10cm
|
Facility
|
OP
|
$14,663.00
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
2549074
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,269.87 |
| Max. Negotiated Rate |
$14,029.56 |
| Rate for Payer: Aetna Commercial |
$13,724.57
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$13,114.59
|
| Rate for Payer: Aetna Managed Medicare |
$4,269.87
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$9,912.19
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$7,624.76
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$7,319.77
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$8,082.25
|
| Rate for Payer: Cash Price |
$4,398.90
|
| Rate for Payer: Cigna Commercial |
$14,029.56
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$8,533.87
|
| Rate for Payer: Health EOS Commercial |
$13,572.07
|
| Rate for Payer: HFN Commercial |
$14,029.56
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$11,437.14
|
| Rate for Payer: Multiplan Commercial |
$12,199.62
|
| Rate for Payer: NAPHCARE Commercial |
$9,149.71
|
| Rate for Payer: Preferred Network Access Commercial |
$14,029.56
|
| Rate for Payer: Quartz Beloit One Network |
$7,472.26
|
| Rate for Payer: Quartz Commercial |
$9,912.19
|
| Rate for Payer: Quartz Medicare Advantage |
$9,149.71
|
| Rate for Payer: The Alliance Commercial |
$7,624.76
|
| Rate for Payer: WEA Trust Commercial |
$8,387.24
|
| Rate for Payer: WPS Commercial |
$11,294.91
|
|
