|
SNARE SENSATION M00562673
|
Facility
|
IP
|
$209.00
|
|
| Hospital Charge Code |
5591389
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$106.51 |
| Max. Negotiated Rate |
$199.97 |
| Rate for Payer: Aetna Commercial |
$195.62
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$186.93
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$115.20
|
| Rate for Payer: Cash Price |
$62.70
|
| Rate for Payer: Cigna Commercial |
$199.97
|
| Rate for Payer: Health EOS Commercial |
$193.45
|
| Rate for Payer: HFN Commercial |
$199.97
|
| Rate for Payer: Multiplan Commercial |
$173.89
|
| Rate for Payer: Preferred Network Access Commercial |
$199.97
|
| Rate for Payer: Quartz Beloit One Network |
$106.51
|
| Rate for Payer: Quartz Commercial |
$130.42
|
| Rate for Payer: WEA Trust Commercial |
$119.55
|
| Rate for Payer: WPS Commercial |
$160.99
|
|
|
SNARE SYSM MINI 4-8 #EN1003008
|
Facility
|
OP
|
$6,654.00
|
|
|
Service Code
|
HCPCS C1773
|
| Hospital Charge Code |
2973710
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,937.64 |
| Max. Negotiated Rate |
$6,366.55 |
| Rate for Payer: Aetna Commercial |
$6,228.14
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,951.34
|
| Rate for Payer: Aetna Managed Medicare |
$1,937.64
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,498.10
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,460.08
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,321.68
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,667.68
|
| Rate for Payer: Cash Price |
$1,996.20
|
| Rate for Payer: Cigna Commercial |
$6,366.55
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,872.63
|
| Rate for Payer: Health EOS Commercial |
$6,158.94
|
| Rate for Payer: HFN Commercial |
$6,366.55
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5,190.12
|
| Rate for Payer: Multiplan Commercial |
$5,536.13
|
| Rate for Payer: NAPHCARE Commercial |
$4,152.10
|
| Rate for Payer: Preferred Network Access Commercial |
$6,366.55
|
| Rate for Payer: Quartz Beloit One Network |
$3,390.88
|
| Rate for Payer: Quartz Commercial |
$4,498.10
|
| Rate for Payer: Quartz Medicare Advantage |
$4,152.10
|
| Rate for Payer: The Alliance Commercial |
$3,460.08
|
| Rate for Payer: WEA Trust Commercial |
$3,806.09
|
| Rate for Payer: WPS Commercial |
$5,125.58
|
|
|
SNARE SYSM MINI 4-8 #EN1003008
|
Facility
|
IP
|
$6,654.00
|
|
|
Service Code
|
HCPCS C1773
|
| Hospital Charge Code |
2973710
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$3,390.88 |
| Max. Negotiated Rate |
$6,366.55 |
| Rate for Payer: Aetna Commercial |
$6,228.14
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,951.34
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,667.68
|
| Rate for Payer: Cash Price |
$1,996.20
|
| Rate for Payer: Cigna Commercial |
$6,366.55
|
| Rate for Payer: Health EOS Commercial |
$6,158.94
|
| Rate for Payer: HFN Commercial |
$6,366.55
|
| Rate for Payer: Multiplan Commercial |
$5,536.13
|
| Rate for Payer: Preferred Network Access Commercial |
$6,366.55
|
| Rate for Payer: Quartz Beloit One Network |
$3,390.88
|
| Rate for Payer: Quartz Commercial |
$4,152.10
|
| Rate for Payer: WEA Trust Commercial |
$3,806.09
|
| Rate for Payer: WPS Commercial |
$5,125.58
|
|
|
SNARE SYSTEM 6-10MM #EN2006010
|
Facility
|
OP
|
$6,298.00
|
|
|
Service Code
|
HCPCS C1773
|
| Hospital Charge Code |
2973522
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,833.98 |
| Max. Negotiated Rate |
$6,025.93 |
| Rate for Payer: Aetna Commercial |
$5,894.93
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,632.93
|
| Rate for Payer: Aetna Managed Medicare |
$1,833.98
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,257.45
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,274.96
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,143.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,471.46
|
| Rate for Payer: Cash Price |
$1,889.40
|
| Rate for Payer: Cigna Commercial |
$6,025.93
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,665.44
|
| Rate for Payer: Health EOS Commercial |
$5,829.43
|
| Rate for Payer: HFN Commercial |
$6,025.93
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,912.44
|
| Rate for Payer: Multiplan Commercial |
$5,239.94
|
| Rate for Payer: NAPHCARE Commercial |
$3,929.95
|
| Rate for Payer: Preferred Network Access Commercial |
$6,025.93
|
| Rate for Payer: Quartz Beloit One Network |
$3,209.46
|
| Rate for Payer: Quartz Commercial |
$4,257.45
|
| Rate for Payer: Quartz Medicare Advantage |
$3,929.95
|
| Rate for Payer: The Alliance Commercial |
$3,274.96
|
| Rate for Payer: WEA Trust Commercial |
$3,602.46
|
| Rate for Payer: WPS Commercial |
$4,851.35
|
|
|
SNARE SYSTEM 6-10MM #EN2006010
|
Facility
|
IP
|
$6,298.00
|
|
|
Service Code
|
HCPCS C1773
|
| Hospital Charge Code |
2973522
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$3,209.46 |
| Max. Negotiated Rate |
$6,025.93 |
| Rate for Payer: Aetna Commercial |
$5,894.93
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,632.93
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,471.46
|
| Rate for Payer: Cash Price |
$1,889.40
|
| Rate for Payer: Cigna Commercial |
$6,025.93
|
| Rate for Payer: Health EOS Commercial |
$5,829.43
|
| Rate for Payer: HFN Commercial |
$6,025.93
|
| Rate for Payer: Multiplan Commercial |
$5,239.94
|
| Rate for Payer: Preferred Network Access Commercial |
$6,025.93
|
| Rate for Payer: Quartz Beloit One Network |
$3,209.46
|
| Rate for Payer: Quartz Commercial |
$3,929.95
|
| Rate for Payer: WEA Trust Commercial |
$3,602.46
|
| Rate for Payer: WPS Commercial |
$4,851.35
|
|
|
SNARE SYSTEM 9-15MM #EN2006015
|
Facility
|
IP
|
$6,298.00
|
|
|
Service Code
|
HCPCS C1773
|
| Hospital Charge Code |
2973523
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$3,209.46 |
| Max. Negotiated Rate |
$6,025.93 |
| Rate for Payer: Aetna Commercial |
$5,894.93
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,632.93
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,471.46
|
| Rate for Payer: Cash Price |
$1,889.40
|
| Rate for Payer: Cigna Commercial |
$6,025.93
|
| Rate for Payer: Health EOS Commercial |
$5,829.43
|
| Rate for Payer: HFN Commercial |
$6,025.93
|
| Rate for Payer: Multiplan Commercial |
$5,239.94
|
| Rate for Payer: Preferred Network Access Commercial |
$6,025.93
|
| Rate for Payer: Quartz Beloit One Network |
$3,209.46
|
| Rate for Payer: Quartz Commercial |
$3,929.95
|
| Rate for Payer: WEA Trust Commercial |
$3,602.46
|
| Rate for Payer: WPS Commercial |
$4,851.35
|
|
|
SNARE SYSTEM 9-15MM #EN2006015
|
Facility
|
OP
|
$6,298.00
|
|
|
Service Code
|
HCPCS C1773
|
| Hospital Charge Code |
2973523
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,833.98 |
| Max. Negotiated Rate |
$6,025.93 |
| Rate for Payer: Aetna Commercial |
$5,894.93
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,632.93
|
| Rate for Payer: Aetna Managed Medicare |
$1,833.98
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,257.45
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,274.96
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,143.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,471.46
|
| Rate for Payer: Cash Price |
$1,889.40
|
| Rate for Payer: Cigna Commercial |
$6,025.93
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,665.44
|
| Rate for Payer: Health EOS Commercial |
$5,829.43
|
| Rate for Payer: HFN Commercial |
$6,025.93
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,912.44
|
| Rate for Payer: Multiplan Commercial |
$5,239.94
|
| Rate for Payer: NAPHCARE Commercial |
$3,929.95
|
| Rate for Payer: Preferred Network Access Commercial |
$6,025.93
|
| Rate for Payer: Quartz Beloit One Network |
$3,209.46
|
| Rate for Payer: Quartz Commercial |
$4,257.45
|
| Rate for Payer: Quartz Medicare Advantage |
$3,929.95
|
| Rate for Payer: The Alliance Commercial |
$3,274.96
|
| Rate for Payer: WEA Trust Commercial |
$3,602.46
|
| Rate for Payer: WPS Commercial |
$4,851.35
|
|
|
Snip incision Of Lacrimal Punctum
|
Professional
|
Both
|
$462.00
|
|
|
Service Code
|
CPT 68440
|
| Hospital Charge Code |
1188913
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$31.31 |
| Max. Negotiated Rate |
$456.46 |
| Rate for Payer: Aetna Commercial |
$456.46
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$413.21
|
| Rate for Payer: Aetna Managed Medicare |
$90.36
|
| Rate for Payer: Anthem Medicare Advantage |
$90.36
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$90.36
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$90.36
|
| Rate for Payer: Cash Price |
$138.60
|
| Rate for Payer: Cash Price |
$138.60
|
| Rate for Payer: Cash Price |
$138.60
|
| Rate for Payer: Cigna Commercial |
$456.46
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$31.31
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$90.36
|
| Rate for Payer: Health EOS Commercial |
$437.24
|
| Rate for Payer: HFN Commercial |
$456.46
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$347.44
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$347.44
|
| Rate for Payer: Independent Care Health Plan Medicare |
$90.36
|
| Rate for Payer: Multiplan Commercial |
$384.38
|
| Rate for Payer: NAPHCARE Commercial |
$135.53
|
| Rate for Payer: Preferred Network Access Commercial |
$456.46
|
| Rate for Payer: Quartz Beloit One Network |
$211.41
|
| Rate for Payer: Quartz Commercial |
$273.87
|
| Rate for Payer: Quartz Medicare Advantage |
$90.36
|
| Rate for Payer: The Alliance Commercial |
$384.01
|
| Rate for Payer: United Healthcare Medicaid |
$31.31
|
| Rate for Payer: United Healthcare Medicare Advantage |
$90.36
|
| Rate for Payer: WEA Trust Commercial |
$264.26
|
| Rate for Payer: WPS Commercial |
$406.60
|
|
|
Snip Incision of Lacrimal Punctum 6844050
|
Professional
|
Both
|
$922.00
|
|
|
Service Code
|
CPT 68440 50
|
| Hospital Charge Code |
5206607
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$31.31 |
| Max. Negotiated Rate |
$910.94 |
| Rate for Payer: Aetna Commercial |
$910.94
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$824.64
|
| Rate for Payer: Cash Price |
$276.60
|
| Rate for Payer: Cash Price |
$276.60
|
| Rate for Payer: Cash Price |
$276.60
|
| Rate for Payer: Cigna Commercial |
$910.94
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$31.31
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$575.33
|
| Rate for Payer: Health EOS Commercial |
$872.58
|
| Rate for Payer: HFN Commercial |
$910.94
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$347.44
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$347.44
|
| Rate for Payer: Multiplan Commercial |
$767.10
|
| Rate for Payer: Preferred Network Access Commercial |
$910.94
|
| Rate for Payer: Quartz Beloit One Network |
$421.91
|
| Rate for Payer: Quartz Commercial |
$546.56
|
| Rate for Payer: The Alliance Commercial |
$479.44
|
| Rate for Payer: United Healthcare Medicaid |
$31.31
|
| Rate for Payer: WEA Trust Commercial |
$527.38
|
| Rate for Payer: WPS Commercial |
$710.22
|
|
|
SOCK AID ADULT PLASTIC #2086
|
Facility
|
IP
|
$145.00
|
|
| Hospital Charge Code |
2970544
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$73.89 |
| Max. Negotiated Rate |
$138.74 |
| Rate for Payer: Aetna Commercial |
$135.72
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$129.69
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$79.92
|
| Rate for Payer: Cash Price |
$43.50
|
| Rate for Payer: Cigna Commercial |
$138.74
|
| Rate for Payer: Health EOS Commercial |
$134.21
|
| Rate for Payer: HFN Commercial |
$138.74
|
| Rate for Payer: Multiplan Commercial |
$120.64
|
| Rate for Payer: Preferred Network Access Commercial |
$138.74
|
| Rate for Payer: Quartz Beloit One Network |
$73.89
|
| Rate for Payer: Quartz Commercial |
$90.48
|
| Rate for Payer: WEA Trust Commercial |
$82.94
|
| Rate for Payer: WPS Commercial |
$111.69
|
|
|
SOCK AID ADULT PLASTIC #2086
|
Facility
|
OP
|
$145.00
|
|
| Hospital Charge Code |
2970544
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$42.22 |
| Max. Negotiated Rate |
$138.74 |
| Rate for Payer: Aetna Commercial |
$135.72
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$129.69
|
| Rate for Payer: Aetna Managed Medicare |
$42.22
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$98.02
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$75.40
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$72.38
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$79.92
|
| Rate for Payer: Cash Price |
$43.50
|
| Rate for Payer: Cigna Commercial |
$138.74
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$84.39
|
| Rate for Payer: Health EOS Commercial |
$134.21
|
| Rate for Payer: HFN Commercial |
$138.74
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$113.10
|
| Rate for Payer: Multiplan Commercial |
$120.64
|
| Rate for Payer: NAPHCARE Commercial |
$90.48
|
| Rate for Payer: Preferred Network Access Commercial |
$138.74
|
| Rate for Payer: Quartz Beloit One Network |
$73.89
|
| Rate for Payer: Quartz Commercial |
$98.02
|
| Rate for Payer: Quartz Medicare Advantage |
$90.48
|
| Rate for Payer: The Alliance Commercial |
$75.40
|
| Rate for Payer: WEA Trust Commercial |
$82.94
|
| Rate for Payer: WPS Commercial |
$111.69
|
|
|
SOCK AIDE ADULT PLASTIC #2083
|
Facility
|
IP
|
$108.00
|
|
| Hospital Charge Code |
2970486
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$55.04 |
| Max. Negotiated Rate |
$103.33 |
| Rate for Payer: Aetna Commercial |
$101.09
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$96.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$59.53
|
| Rate for Payer: Cash Price |
$32.40
|
| Rate for Payer: Cigna Commercial |
$103.33
|
| Rate for Payer: Health EOS Commercial |
$99.96
|
| Rate for Payer: HFN Commercial |
$103.33
|
| Rate for Payer: Multiplan Commercial |
$89.86
|
| Rate for Payer: Preferred Network Access Commercial |
$103.33
|
| Rate for Payer: Quartz Beloit One Network |
$55.04
|
| Rate for Payer: Quartz Commercial |
$67.39
|
| Rate for Payer: WEA Trust Commercial |
$61.78
|
| Rate for Payer: WPS Commercial |
$83.19
|
|
|
SOCK AIDE ADULT PLASTIC #2083
|
Facility
|
OP
|
$108.00
|
|
| Hospital Charge Code |
2970486
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$31.45 |
| Max. Negotiated Rate |
$103.33 |
| Rate for Payer: Aetna Commercial |
$101.09
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$96.60
|
| Rate for Payer: Aetna Managed Medicare |
$31.45
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$73.01
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$56.16
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$53.91
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$59.53
|
| Rate for Payer: Cash Price |
$32.40
|
| Rate for Payer: Cigna Commercial |
$103.33
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$62.86
|
| Rate for Payer: Health EOS Commercial |
$99.96
|
| Rate for Payer: HFN Commercial |
$103.33
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$84.24
|
| Rate for Payer: Multiplan Commercial |
$89.86
|
| Rate for Payer: NAPHCARE Commercial |
$67.39
|
| Rate for Payer: Preferred Network Access Commercial |
$103.33
|
| Rate for Payer: Quartz Beloit One Network |
$55.04
|
| Rate for Payer: Quartz Commercial |
$73.01
|
| Rate for Payer: Quartz Medicare Advantage |
$67.39
|
| Rate for Payer: The Alliance Commercial |
$56.16
|
| Rate for Payer: WEA Trust Commercial |
$61.78
|
| Rate for Payer: WPS Commercial |
$83.19
|
|
|
Sock fracture or equal each L3995
|
Facility
|
OP
|
$129.00
|
|
|
Service Code
|
HCPCS L3995
|
| Hospital Charge Code |
4572610
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$27.26 |
| Max. Negotiated Rate |
$191.03 |
| Rate for Payer: Aetna Commercial |
$120.74
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$115.38
|
| Rate for Payer: Aetna Managed Medicare |
$37.56
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$27.26
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$27.26
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$27.26
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$71.10
|
| Rate for Payer: Cash Price |
$38.70
|
| Rate for Payer: Cash Price |
$38.70
|
| Rate for Payer: Cigna Commercial |
$123.43
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$75.08
|
| Rate for Payer: Health EOS Commercial |
$119.40
|
| Rate for Payer: HFN Commercial |
$123.43
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$100.62
|
| Rate for Payer: Multiplan Commercial |
$107.33
|
| Rate for Payer: NAPHCARE Commercial |
$80.50
|
| Rate for Payer: Preferred Network Access Commercial |
$123.43
|
| Rate for Payer: Quartz Beloit One Network |
$65.74
|
| Rate for Payer: Quartz Commercial |
$87.20
|
| Rate for Payer: Quartz Medicare Advantage |
$80.50
|
| Rate for Payer: The Alliance Commercial |
$191.03
|
| Rate for Payer: WEA Trust Commercial |
$73.79
|
| Rate for Payer: WPS Commercial |
$99.37
|
|
|
Sock fracture or equal each L3995
|
Facility
|
IP
|
$129.00
|
|
|
Service Code
|
HCPCS L3995
|
| Hospital Charge Code |
4572610
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$65.74 |
| Max. Negotiated Rate |
$123.43 |
| Rate for Payer: Aetna Commercial |
$120.74
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$115.38
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$71.10
|
| Rate for Payer: Cash Price |
$38.70
|
| Rate for Payer: Cigna Commercial |
$123.43
|
| Rate for Payer: Health EOS Commercial |
$119.40
|
| Rate for Payer: HFN Commercial |
$123.43
|
| Rate for Payer: Multiplan Commercial |
$107.33
|
| Rate for Payer: Preferred Network Access Commercial |
$123.43
|
| Rate for Payer: Quartz Beloit One Network |
$65.74
|
| Rate for Payer: Quartz Commercial |
$80.50
|
| Rate for Payer: WEA Trust Commercial |
$73.79
|
| Rate for Payer: WPS Commercial |
$99.37
|
|
|
Sock fracture or equal each L3995
|
Professional
|
Both
|
$129.00
|
|
|
Service Code
|
HCPCS L3995
|
| Hospital Charge Code |
4572610
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$47.76 |
| Max. Negotiated Rate |
$137.71 |
| Rate for Payer: Aetna Commercial |
$127.45
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$115.38
|
| Rate for Payer: Aetna Managed Medicare |
$47.76
|
| Rate for Payer: Anthem Medicare Advantage |
$47.76
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$47.76
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$47.76
|
| Rate for Payer: Cash Price |
$38.70
|
| Rate for Payer: Cash Price |
$38.70
|
| Rate for Payer: Cigna Commercial |
$127.45
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$67.08
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$47.76
|
| Rate for Payer: Health EOS Commercial |
$122.09
|
| Rate for Payer: HFN Commercial |
$127.45
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$137.71
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$137.71
|
| Rate for Payer: Independent Care Health Plan Medicare |
$47.76
|
| Rate for Payer: Multiplan Commercial |
$107.33
|
| Rate for Payer: NAPHCARE Commercial |
$71.64
|
| Rate for Payer: Preferred Network Access Commercial |
$127.45
|
| Rate for Payer: Quartz Beloit One Network |
$59.03
|
| Rate for Payer: Quartz Commercial |
$76.47
|
| Rate for Payer: Quartz Medicare Advantage |
$47.76
|
| Rate for Payer: The Alliance Commercial |
$131.33
|
| Rate for Payer: United Healthcare Medicare Advantage |
$47.76
|
| Rate for Payer: WEA Trust Commercial |
$73.79
|
| Rate for Payer: WPS Commercial |
$83.57
|
|
|
SOCK SLIPPER YELLOW ADULT XXL 3902-001
|
Facility
|
OP
|
$64.00
|
|
| Hospital Charge Code |
5415018
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$18.64 |
| Max. Negotiated Rate |
$61.24 |
| Rate for Payer: Aetna Commercial |
$59.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$57.24
|
| Rate for Payer: Aetna Managed Medicare |
$18.64
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$43.26
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$33.28
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$31.95
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$35.28
|
| Rate for Payer: Cash Price |
$19.20
|
| Rate for Payer: Cigna Commercial |
$61.24
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$37.25
|
| Rate for Payer: Health EOS Commercial |
$59.24
|
| Rate for Payer: HFN Commercial |
$61.24
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$49.92
|
| Rate for Payer: Multiplan Commercial |
$53.25
|
| Rate for Payer: NAPHCARE Commercial |
$39.94
|
| Rate for Payer: Preferred Network Access Commercial |
$61.24
|
| Rate for Payer: Quartz Beloit One Network |
$32.61
|
| Rate for Payer: Quartz Commercial |
$43.26
|
| Rate for Payer: Quartz Medicare Advantage |
$39.94
|
| Rate for Payer: The Alliance Commercial |
$33.28
|
| Rate for Payer: WEA Trust Commercial |
$36.61
|
| Rate for Payer: WPS Commercial |
$49.30
|
|
|
SOCK SLIPPER YELLOW ADULT XXL 3902-001
|
Facility
|
IP
|
$64.00
|
|
| Hospital Charge Code |
5415018
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$32.61 |
| Max. Negotiated Rate |
$61.24 |
| Rate for Payer: Aetna Commercial |
$59.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$57.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$35.28
|
| Rate for Payer: Cash Price |
$19.20
|
| Rate for Payer: Cigna Commercial |
$61.24
|
| Rate for Payer: Health EOS Commercial |
$59.24
|
| Rate for Payer: HFN Commercial |
$61.24
|
| Rate for Payer: Multiplan Commercial |
$53.25
|
| Rate for Payer: Preferred Network Access Commercial |
$61.24
|
| Rate for Payer: Quartz Beloit One Network |
$32.61
|
| Rate for Payer: Quartz Commercial |
$39.94
|
| Rate for Payer: WEA Trust Commercial |
$36.61
|
| Rate for Payer: WPS Commercial |
$49.30
|
|
|
Sodium Bicarbonate 8.4% Pediatric Syringe 10ml [Med]
|
Facility
|
IP
|
$130.00
|
|
| Hospital Charge Code |
2974980
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$66.25 |
| Max. Negotiated Rate |
$124.38 |
| Rate for Payer: Aetna Commercial |
$121.68
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$116.27
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$71.66
|
| Rate for Payer: Cash Price |
$39.00
|
| Rate for Payer: Cigna Commercial |
$124.38
|
| Rate for Payer: Health EOS Commercial |
$120.33
|
| Rate for Payer: HFN Commercial |
$124.38
|
| Rate for Payer: Multiplan Commercial |
$108.16
|
| Rate for Payer: Preferred Network Access Commercial |
$124.38
|
| Rate for Payer: Quartz Beloit One Network |
$66.25
|
| Rate for Payer: Quartz Commercial |
$81.12
|
| Rate for Payer: WEA Trust Commercial |
$74.36
|
| Rate for Payer: WPS Commercial |
$100.14
|
|
|
Sodium Bicarbonate 8.4% Pediatric Syringe 10ml [Med]
|
Facility
|
OP
|
$130.00
|
|
| Hospital Charge Code |
2974980
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$37.86 |
| Max. Negotiated Rate |
$124.38 |
| Rate for Payer: Aetna Commercial |
$121.68
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$116.27
|
| Rate for Payer: Aetna Managed Medicare |
$37.86
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$87.88
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$67.60
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$64.90
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$71.66
|
| Rate for Payer: Cash Price |
$39.00
|
| Rate for Payer: Cigna Commercial |
$124.38
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$75.66
|
| Rate for Payer: Health EOS Commercial |
$120.33
|
| Rate for Payer: HFN Commercial |
$124.38
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$101.40
|
| Rate for Payer: Multiplan Commercial |
$108.16
|
| Rate for Payer: NAPHCARE Commercial |
$81.12
|
| Rate for Payer: Preferred Network Access Commercial |
$124.38
|
| Rate for Payer: Quartz Beloit One Network |
$66.25
|
| Rate for Payer: Quartz Commercial |
$87.88
|
| Rate for Payer: Quartz Medicare Advantage |
$81.12
|
| Rate for Payer: The Alliance Commercial |
$67.60
|
| Rate for Payer: WEA Trust Commercial |
$74.36
|
| Rate for Payer: WPS Commercial |
$100.14
|
|
|
Sodium Chloride 0.9% 250ml IRR Soln
|
Facility
|
OP
|
$32.00
|
|
| Hospital Charge Code |
4065118
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.32 |
| Max. Negotiated Rate |
$30.62 |
| Rate for Payer: Aetna Commercial |
$29.95
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$28.62
|
| Rate for Payer: Aetna Managed Medicare |
$9.32
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$21.63
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$16.64
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$15.97
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$17.64
|
| Rate for Payer: Cash Price |
$9.60
|
| Rate for Payer: Cigna Commercial |
$30.62
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$18.62
|
| Rate for Payer: Health EOS Commercial |
$29.62
|
| Rate for Payer: HFN Commercial |
$30.62
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$24.96
|
| Rate for Payer: Multiplan Commercial |
$26.62
|
| Rate for Payer: NAPHCARE Commercial |
$19.97
|
| Rate for Payer: Preferred Network Access Commercial |
$30.62
|
| Rate for Payer: Quartz Beloit One Network |
$16.31
|
| Rate for Payer: Quartz Commercial |
$21.63
|
| Rate for Payer: Quartz Medicare Advantage |
$19.97
|
| Rate for Payer: The Alliance Commercial |
$16.64
|
| Rate for Payer: WEA Trust Commercial |
$18.30
|
| Rate for Payer: WPS Commercial |
$24.65
|
|
|
Sodium Chloride 0.9% 250ml IRR Soln
|
Professional
|
Both
|
$32.00
|
|
| Hospital Charge Code |
4065118
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$14.64 |
| Max. Negotiated Rate |
$31.62 |
| Rate for Payer: Aetna Commercial |
$31.62
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$28.62
|
| Rate for Payer: Cash Price |
$9.60
|
| Rate for Payer: Cigna Commercial |
$31.62
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$16.64
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$19.97
|
| Rate for Payer: Health EOS Commercial |
$30.28
|
| Rate for Payer: HFN Commercial |
$31.62
|
| Rate for Payer: Multiplan Commercial |
$26.62
|
| Rate for Payer: Preferred Network Access Commercial |
$31.62
|
| Rate for Payer: Quartz Beloit One Network |
$14.64
|
| Rate for Payer: Quartz Commercial |
$18.97
|
| Rate for Payer: The Alliance Commercial |
$16.64
|
| Rate for Payer: WEA Trust Commercial |
$18.30
|
| Rate for Payer: WPS Commercial |
$24.65
|
|
|
Sodium Chloride 0.9% 250ml IRR Soln
|
Facility
|
IP
|
$32.00
|
|
| Hospital Charge Code |
4065118
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$16.31 |
| Max. Negotiated Rate |
$30.62 |
| Rate for Payer: Aetna Commercial |
$29.95
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$28.62
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$17.64
|
| Rate for Payer: Cash Price |
$9.60
|
| Rate for Payer: Cigna Commercial |
$30.62
|
| Rate for Payer: Health EOS Commercial |
$29.62
|
| Rate for Payer: HFN Commercial |
$30.62
|
| Rate for Payer: Multiplan Commercial |
$26.62
|
| Rate for Payer: Preferred Network Access Commercial |
$30.62
|
| Rate for Payer: Quartz Beloit One Network |
$16.31
|
| Rate for Payer: Quartz Commercial |
$19.97
|
| Rate for Payer: WEA Trust Commercial |
$18.30
|
| Rate for Payer: WPS Commercial |
$24.65
|
|
|
Sodium Chloride 0.9% IV 500 ML J7040
|
Facility
|
IP
|
$100.00
|
|
|
Service Code
|
HCPCS J7040
|
| Hospital Charge Code |
4027269
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$50.96 |
| Max. Negotiated Rate |
$95.68 |
| Rate for Payer: Aetna Commercial |
$93.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$89.44
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$55.12
|
| Rate for Payer: Cash Price |
$30.00
|
| Rate for Payer: Cigna Commercial |
$95.68
|
| Rate for Payer: Health EOS Commercial |
$92.56
|
| Rate for Payer: HFN Commercial |
$95.68
|
| Rate for Payer: Multiplan Commercial |
$83.20
|
| Rate for Payer: Preferred Network Access Commercial |
$95.68
|
| Rate for Payer: Quartz Beloit One Network |
$50.96
|
| Rate for Payer: Quartz Commercial |
$62.40
|
| Rate for Payer: WEA Trust Commercial |
$57.20
|
| Rate for Payer: WPS Commercial |
$77.03
|
|
|
Sodium Chloride 0.9% IV 500 ML J7040
|
Facility
|
OP
|
$100.00
|
|
|
Service Code
|
HCPCS J7040
|
| Hospital Charge Code |
4027269
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.79 |
| Max. Negotiated Rate |
$95.68 |
| Rate for Payer: Aetna Commercial |
$93.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$89.44
|
| Rate for Payer: Aetna Managed Medicare |
$29.12
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$67.60
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$52.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$49.92
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$55.12
|
| Rate for Payer: Cash Price |
$30.00
|
| Rate for Payer: Cash Price |
$30.00
|
| Rate for Payer: Cigna Commercial |
$95.68
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1.79
|
| Rate for Payer: Health EOS Commercial |
$92.56
|
| Rate for Payer: HFN Commercial |
$95.68
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$78.00
|
| Rate for Payer: Multiplan Commercial |
$83.20
|
| Rate for Payer: NAPHCARE Commercial |
$62.40
|
| Rate for Payer: Preferred Network Access Commercial |
$95.68
|
| Rate for Payer: Quartz Beloit One Network |
$50.96
|
| Rate for Payer: Quartz Commercial |
$67.60
|
| Rate for Payer: Quartz Medicare Advantage |
$62.40
|
| Rate for Payer: The Alliance Commercial |
$5.37
|
| Rate for Payer: WEA Trust Commercial |
$57.20
|
| Rate for Payer: WPS Commercial |
$3.39
|
|
