|
SOCK AID ADULT PLASTIC #2086
|
Facility
|
IP
|
$145.00
|
|
| Hospital Charge Code |
2970544
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$71.05 |
| Max. Negotiated Rate |
$133.40 |
| Rate for Payer: Aetna Commercial |
$130.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$124.70
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$76.85
|
| Rate for Payer: Cash Price |
$43.50
|
| Rate for Payer: Cigna Commercial |
$133.40
|
| Rate for Payer: Health EOS Commercial |
$129.05
|
| Rate for Payer: HFN Commercial |
$133.40
|
| Rate for Payer: Multiplan Commercial |
$116.00
|
| Rate for Payer: NAPHCARE Commercial |
$87.00
|
| Rate for Payer: Preferred Network Access Commercial |
$133.40
|
| Rate for Payer: Quartz Beloit One Network |
$71.05
|
| Rate for Payer: Quartz Commercial |
$87.00
|
| Rate for Payer: WEA Trust Commercial |
$79.75
|
| Rate for Payer: WPS Commercial |
$107.40
|
|
|
SOCK AID ADULT PLASTIC #2086
|
Facility
|
OP
|
$145.00
|
|
| Hospital Charge Code |
2970544
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$40.60 |
| Max. Negotiated Rate |
$580.00 |
| Rate for Payer: Aetna Commercial |
$130.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$124.70
|
| Rate for Payer: Aetna Managed Medicare |
$40.60
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$94.25
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$72.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$69.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$76.85
|
| Rate for Payer: Cash Price |
$43.50
|
| Rate for Payer: Cigna Commercial |
$133.40
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$81.14
|
| Rate for Payer: Health EOS Commercial |
$129.05
|
| Rate for Payer: HFN Commercial |
$133.40
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$108.75
|
| Rate for Payer: Multiplan Commercial |
$116.00
|
| Rate for Payer: NAPHCARE Commercial |
$87.00
|
| Rate for Payer: Preferred Network Access Commercial |
$133.40
|
| Rate for Payer: Quartz Beloit One Network |
$71.05
|
| Rate for Payer: Quartz Commercial |
$94.25
|
| Rate for Payer: Quartz Medicare Advantage |
$87.00
|
| Rate for Payer: The Alliance Commercial |
$580.00
|
| Rate for Payer: WEA Trust Commercial |
$79.75
|
| Rate for Payer: WPS Commercial |
$107.40
|
|
|
SOCK AIDE ADULT PLASTIC #2083
|
Facility
|
IP
|
$108.00
|
|
| Hospital Charge Code |
2970486
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$52.92 |
| Max. Negotiated Rate |
$99.36 |
| Rate for Payer: Aetna Commercial |
$97.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$92.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$57.24
|
| Rate for Payer: Cash Price |
$32.40
|
| Rate for Payer: Cigna Commercial |
$99.36
|
| Rate for Payer: Health EOS Commercial |
$96.12
|
| Rate for Payer: HFN Commercial |
$99.36
|
| Rate for Payer: Multiplan Commercial |
$86.40
|
| Rate for Payer: NAPHCARE Commercial |
$64.80
|
| Rate for Payer: Preferred Network Access Commercial |
$99.36
|
| Rate for Payer: Quartz Beloit One Network |
$52.92
|
| Rate for Payer: Quartz Commercial |
$64.80
|
| Rate for Payer: WEA Trust Commercial |
$59.40
|
| Rate for Payer: WPS Commercial |
$80.00
|
|
|
SOCK AIDE ADULT PLASTIC #2083
|
Facility
|
OP
|
$108.00
|
|
| Hospital Charge Code |
2970486
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$30.24 |
| Max. Negotiated Rate |
$432.00 |
| Rate for Payer: Aetna Commercial |
$97.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$92.88
|
| Rate for Payer: Aetna Managed Medicare |
$30.24
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$70.20
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$54.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$51.84
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$57.24
|
| Rate for Payer: Cash Price |
$32.40
|
| Rate for Payer: Cigna Commercial |
$99.36
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$60.44
|
| Rate for Payer: Health EOS Commercial |
$96.12
|
| Rate for Payer: HFN Commercial |
$99.36
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$81.00
|
| Rate for Payer: Multiplan Commercial |
$86.40
|
| Rate for Payer: NAPHCARE Commercial |
$64.80
|
| Rate for Payer: Preferred Network Access Commercial |
$99.36
|
| Rate for Payer: Quartz Beloit One Network |
$52.92
|
| Rate for Payer: Quartz Commercial |
$70.20
|
| Rate for Payer: Quartz Medicare Advantage |
$64.80
|
| Rate for Payer: The Alliance Commercial |
$432.00
|
| Rate for Payer: WEA Trust Commercial |
$59.40
|
| Rate for Payer: WPS Commercial |
$80.00
|
|
|
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 |
$63.21 |
| Max. Negotiated Rate |
$118.68 |
| Rate for Payer: Aetna Commercial |
$116.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$110.94
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$68.37
|
| Rate for Payer: Cash Price |
$38.70
|
| Rate for Payer: Cigna Commercial |
$118.68
|
| Rate for Payer: Health EOS Commercial |
$114.81
|
| Rate for Payer: HFN Commercial |
$118.68
|
| Rate for Payer: Multiplan Commercial |
$103.20
|
| Rate for Payer: NAPHCARE Commercial |
$77.40
|
| Rate for Payer: Preferred Network Access Commercial |
$118.68
|
| Rate for Payer: Quartz Beloit One Network |
$63.21
|
| Rate for Payer: Quartz Commercial |
$77.40
|
| Rate for Payer: WEA Trust Commercial |
$70.95
|
| Rate for Payer: WPS Commercial |
$95.55
|
|
|
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 |
$26.21 |
| Max. Negotiated Rate |
$516.00 |
| Rate for Payer: Aetna Commercial |
$116.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$110.94
|
| Rate for Payer: Aetna Managed Medicare |
$36.12
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$26.21
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$26.21
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$26.21
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$68.37
|
| Rate for Payer: Cash Price |
$38.70
|
| Rate for Payer: Cash Price |
$38.70
|
| Rate for Payer: Cigna Commercial |
$118.68
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$72.19
|
| Rate for Payer: Health EOS Commercial |
$114.81
|
| Rate for Payer: HFN Commercial |
$118.68
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$96.75
|
| Rate for Payer: Multiplan Commercial |
$103.20
|
| Rate for Payer: NAPHCARE Commercial |
$77.40
|
| Rate for Payer: Preferred Network Access Commercial |
$118.68
|
| Rate for Payer: Quartz Beloit One Network |
$63.21
|
| Rate for Payer: Quartz Commercial |
$83.85
|
| Rate for Payer: Quartz Medicare Advantage |
$77.40
|
| Rate for Payer: The Alliance Commercial |
$516.00
|
| Rate for Payer: WEA Trust Commercial |
$70.95
|
| Rate for Payer: WPS Commercial |
$95.55
|
|
|
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 |
$56.76 |
| Max. Negotiated Rate |
$132.41 |
| Rate for Payer: Aetna Commercial |
$122.55
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$110.94
|
| Rate for Payer: Cash Price |
$38.70
|
| Rate for Payer: Cash Price |
$38.70
|
| Rate for Payer: Cigna Commercial |
$122.55
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$64.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$77.40
|
| Rate for Payer: Health EOS Commercial |
$117.39
|
| Rate for Payer: HFN Commercial |
$122.55
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$132.41
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$132.41
|
| Rate for Payer: Multiplan Commercial |
$103.20
|
| Rate for Payer: Preferred Network Access Commercial |
$122.55
|
| Rate for Payer: Quartz Beloit One Network |
$56.76
|
| Rate for Payer: Quartz Commercial |
$73.53
|
| Rate for Payer: The Alliance Commercial |
$64.50
|
| Rate for Payer: WEA Trust Commercial |
$70.95
|
| Rate for Payer: WPS Commercial |
$95.55
|
|
|
SOCK SLIPPER YELLOW ADULT XXL 3902-001
|
Facility
|
OP
|
$64.00
|
|
| Hospital Charge Code |
5415018
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$17.92 |
| Max. Negotiated Rate |
$256.00 |
| Rate for Payer: Aetna Commercial |
$57.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$55.04
|
| Rate for Payer: Aetna Managed Medicare |
$17.92
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$41.60
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$32.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$30.72
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$33.92
|
| Rate for Payer: Cash Price |
$19.20
|
| Rate for Payer: Cigna Commercial |
$58.88
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$35.81
|
| Rate for Payer: Health EOS Commercial |
$56.96
|
| Rate for Payer: HFN Commercial |
$58.88
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$48.00
|
| Rate for Payer: Multiplan Commercial |
$51.20
|
| Rate for Payer: NAPHCARE Commercial |
$38.40
|
| Rate for Payer: Preferred Network Access Commercial |
$58.88
|
| Rate for Payer: Quartz Beloit One Network |
$31.36
|
| Rate for Payer: Quartz Commercial |
$41.60
|
| Rate for Payer: Quartz Medicare Advantage |
$38.40
|
| Rate for Payer: The Alliance Commercial |
$256.00
|
| Rate for Payer: WEA Trust Commercial |
$35.20
|
| Rate for Payer: WPS Commercial |
$47.40
|
|
|
SOCK SLIPPER YELLOW ADULT XXL 3902-001
|
Facility
|
IP
|
$64.00
|
|
| Hospital Charge Code |
5415018
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$31.36 |
| Max. Negotiated Rate |
$58.88 |
| Rate for Payer: Aetna Commercial |
$57.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$55.04
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$33.92
|
| Rate for Payer: Cash Price |
$19.20
|
| Rate for Payer: Cigna Commercial |
$58.88
|
| Rate for Payer: Health EOS Commercial |
$56.96
|
| Rate for Payer: HFN Commercial |
$58.88
|
| Rate for Payer: Multiplan Commercial |
$51.20
|
| Rate for Payer: NAPHCARE Commercial |
$38.40
|
| Rate for Payer: Preferred Network Access Commercial |
$58.88
|
| Rate for Payer: Quartz Beloit One Network |
$31.36
|
| Rate for Payer: Quartz Commercial |
$38.40
|
| Rate for Payer: WEA Trust Commercial |
$35.20
|
| Rate for Payer: WPS Commercial |
$47.40
|
|
|
Sodium Bicarbonate 8.4% Pediatric Syringe 10ml [Med]
|
Facility
|
OP
|
$130.00
|
|
| Hospital Charge Code |
2974980
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$36.40 |
| Max. Negotiated Rate |
$520.00 |
| Rate for Payer: Aetna Commercial |
$117.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$111.80
|
| Rate for Payer: Aetna Managed Medicare |
$36.40
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$84.50
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$65.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$62.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$68.90
|
| Rate for Payer: Cash Price |
$39.00
|
| Rate for Payer: Cigna Commercial |
$119.60
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$72.75
|
| Rate for Payer: Health EOS Commercial |
$115.70
|
| Rate for Payer: HFN Commercial |
$119.60
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$97.50
|
| Rate for Payer: Multiplan Commercial |
$104.00
|
| Rate for Payer: NAPHCARE Commercial |
$78.00
|
| Rate for Payer: Preferred Network Access Commercial |
$119.60
|
| Rate for Payer: Quartz Beloit One Network |
$63.70
|
| Rate for Payer: Quartz Commercial |
$84.50
|
| Rate for Payer: Quartz Medicare Advantage |
$78.00
|
| Rate for Payer: The Alliance Commercial |
$520.00
|
| Rate for Payer: WEA Trust Commercial |
$71.50
|
| Rate for Payer: WPS Commercial |
$96.29
|
|
|
Sodium Bicarbonate 8.4% Pediatric Syringe 10ml [Med]
|
Facility
|
IP
|
$130.00
|
|
| Hospital Charge Code |
2974980
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$63.70 |
| Max. Negotiated Rate |
$119.60 |
| Rate for Payer: Aetna Commercial |
$117.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$111.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$68.90
|
| Rate for Payer: Cash Price |
$39.00
|
| Rate for Payer: Cigna Commercial |
$119.60
|
| Rate for Payer: Health EOS Commercial |
$115.70
|
| Rate for Payer: HFN Commercial |
$119.60
|
| Rate for Payer: Multiplan Commercial |
$104.00
|
| Rate for Payer: NAPHCARE Commercial |
$78.00
|
| Rate for Payer: Preferred Network Access Commercial |
$119.60
|
| Rate for Payer: Quartz Beloit One Network |
$63.70
|
| Rate for Payer: Quartz Commercial |
$78.00
|
| Rate for Payer: WEA Trust Commercial |
$71.50
|
| Rate for Payer: WPS Commercial |
$96.29
|
|
|
Sodium Chloride 0.9% 250ml IRR Soln
|
Professional
|
Both
|
$32.00
|
|
| Hospital Charge Code |
4065118
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$14.08 |
| Max. Negotiated Rate |
$30.40 |
| Rate for Payer: Aetna Commercial |
$30.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$27.52
|
| Rate for Payer: Cash Price |
$9.60
|
| Rate for Payer: Cigna Commercial |
$30.40
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$16.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$19.20
|
| Rate for Payer: Health EOS Commercial |
$29.12
|
| Rate for Payer: HFN Commercial |
$30.40
|
| Rate for Payer: Multiplan Commercial |
$25.60
|
| Rate for Payer: Preferred Network Access Commercial |
$30.40
|
| Rate for Payer: Quartz Beloit One Network |
$14.08
|
| Rate for Payer: Quartz Commercial |
$18.24
|
| Rate for Payer: The Alliance Commercial |
$16.00
|
| Rate for Payer: WEA Trust Commercial |
$17.60
|
| Rate for Payer: WPS Commercial |
$23.70
|
|
|
Sodium Chloride 0.9% 250ml IRR Soln
|
Facility
|
IP
|
$32.00
|
|
| Hospital Charge Code |
4065118
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$15.68 |
| Max. Negotiated Rate |
$29.44 |
| Rate for Payer: Aetna Commercial |
$28.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$27.52
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$16.96
|
| Rate for Payer: Cash Price |
$9.60
|
| Rate for Payer: Cigna Commercial |
$29.44
|
| Rate for Payer: Health EOS Commercial |
$28.48
|
| Rate for Payer: HFN Commercial |
$29.44
|
| Rate for Payer: Multiplan Commercial |
$25.60
|
| Rate for Payer: NAPHCARE Commercial |
$19.20
|
| Rate for Payer: Preferred Network Access Commercial |
$29.44
|
| Rate for Payer: Quartz Beloit One Network |
$15.68
|
| Rate for Payer: Quartz Commercial |
$19.20
|
| Rate for Payer: WEA Trust Commercial |
$17.60
|
| Rate for Payer: WPS Commercial |
$23.70
|
|
|
Sodium Chloride 0.9% 250ml IRR Soln
|
Facility
|
OP
|
$32.00
|
|
| Hospital Charge Code |
4065118
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.96 |
| Max. Negotiated Rate |
$128.00 |
| Rate for Payer: Aetna Commercial |
$28.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$27.52
|
| Rate for Payer: Aetna Managed Medicare |
$8.96
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$20.80
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$16.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$15.36
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$16.96
|
| Rate for Payer: Cash Price |
$9.60
|
| Rate for Payer: Cigna Commercial |
$29.44
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$17.91
|
| Rate for Payer: Health EOS Commercial |
$28.48
|
| Rate for Payer: HFN Commercial |
$29.44
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$24.00
|
| Rate for Payer: Multiplan Commercial |
$25.60
|
| Rate for Payer: NAPHCARE Commercial |
$19.20
|
| Rate for Payer: Preferred Network Access Commercial |
$29.44
|
| Rate for Payer: Quartz Beloit One Network |
$15.68
|
| Rate for Payer: Quartz Commercial |
$20.80
|
| Rate for Payer: Quartz Medicare Advantage |
$19.20
|
| Rate for Payer: The Alliance Commercial |
$128.00
|
| Rate for Payer: WEA Trust Commercial |
$17.60
|
| Rate for Payer: WPS Commercial |
$23.70
|
|
|
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 |
$49.00 |
| Max. Negotiated Rate |
$92.00 |
| Rate for Payer: Aetna Commercial |
$90.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$86.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$53.00
|
| Rate for Payer: Cash Price |
$30.00
|
| Rate for Payer: Cigna Commercial |
$92.00
|
| Rate for Payer: Health EOS Commercial |
$89.00
|
| Rate for Payer: HFN Commercial |
$92.00
|
| Rate for Payer: Multiplan Commercial |
$80.00
|
| Rate for Payer: NAPHCARE Commercial |
$60.00
|
| Rate for Payer: Preferred Network Access Commercial |
$92.00
|
| Rate for Payer: Quartz Beloit One Network |
$49.00
|
| Rate for Payer: Quartz Commercial |
$60.00
|
| Rate for Payer: WEA Trust Commercial |
$55.00
|
| Rate for Payer: WPS Commercial |
$74.07
|
|
|
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 |
$1.73 |
| Max. Negotiated Rate |
$400.00 |
| Rate for Payer: Aetna Commercial |
$90.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$86.00
|
| Rate for Payer: Aetna Managed Medicare |
$28.00
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$65.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$50.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$48.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$53.00
|
| Rate for Payer: Cash Price |
$30.00
|
| Rate for Payer: Cash Price |
$30.00
|
| Rate for Payer: Cigna Commercial |
$92.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1.73
|
| Rate for Payer: Health EOS Commercial |
$89.00
|
| Rate for Payer: HFN Commercial |
$92.00
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$75.00
|
| Rate for Payer: Multiplan Commercial |
$80.00
|
| Rate for Payer: NAPHCARE Commercial |
$60.00
|
| Rate for Payer: Preferred Network Access Commercial |
$92.00
|
| Rate for Payer: Quartz Beloit One Network |
$49.00
|
| Rate for Payer: Quartz Commercial |
$65.00
|
| Rate for Payer: Quartz Medicare Advantage |
$60.00
|
| Rate for Payer: The Alliance Commercial |
$400.00
|
| Rate for Payer: WEA Trust Commercial |
$55.00
|
| Rate for Payer: WPS Commercial |
$3.26
|
|
|
Sodium Chloride 0.9% IV 500 ML J7040
|
Professional
|
Both
|
$100.00
|
|
|
Service Code
|
HCPCS J7040
|
| Hospital Charge Code |
4027269
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.30 |
| Max. Negotiated Rate |
$95.00 |
| Rate for Payer: Aetna Commercial |
$95.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$86.00
|
| Rate for Payer: Cash Price |
$30.00
|
| Rate for Payer: Cash Price |
$30.00
|
| Rate for Payer: Cigna Commercial |
$95.00
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$1.30
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1.30
|
| Rate for Payer: Health EOS Commercial |
$91.00
|
| Rate for Payer: HFN Commercial |
$95.00
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2.04
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$2.04
|
| Rate for Payer: Multiplan Commercial |
$80.00
|
| Rate for Payer: Preferred Network Access Commercial |
$95.00
|
| Rate for Payer: Quartz Beloit One Network |
$44.00
|
| Rate for Payer: Quartz Commercial |
$57.00
|
| Rate for Payer: The Alliance Commercial |
$50.00
|
| Rate for Payer: United Healthcare Medicaid |
$1.30
|
| Rate for Payer: WEA Trust Commercial |
$55.00
|
| Rate for Payer: WPS Commercial |
$3.26
|
|
|
SODIUM CHLORIDE 0.9% PF 10ML (MED)
|
Facility
|
IP
|
$7.00
|
|
| Hospital Charge Code |
5923704
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.43 |
| Max. Negotiated Rate |
$6.44 |
| Rate for Payer: Aetna Commercial |
$6.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6.02
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3.71
|
| Rate for Payer: Cash Price |
$2.10
|
| Rate for Payer: Cigna Commercial |
$6.44
|
| Rate for Payer: Health EOS Commercial |
$6.23
|
| Rate for Payer: HFN Commercial |
$6.44
|
| Rate for Payer: Multiplan Commercial |
$5.60
|
| Rate for Payer: NAPHCARE Commercial |
$4.20
|
| Rate for Payer: Preferred Network Access Commercial |
$6.44
|
| Rate for Payer: Quartz Beloit One Network |
$3.43
|
| Rate for Payer: Quartz Commercial |
$4.20
|
| Rate for Payer: WEA Trust Commercial |
$3.85
|
| Rate for Payer: WPS Commercial |
$5.18
|
|
|
SODIUM CHLORIDE 0.9% PF 10ML (MED)
|
Facility
|
OP
|
$7.00
|
|
| Hospital Charge Code |
5923704
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.96 |
| Max. Negotiated Rate |
$28.00 |
| Rate for Payer: Aetna Commercial |
$6.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6.02
|
| Rate for Payer: Aetna Managed Medicare |
$1.96
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4.55
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3.36
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3.71
|
| Rate for Payer: Cash Price |
$2.10
|
| Rate for Payer: Cigna Commercial |
$6.44
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3.92
|
| Rate for Payer: Health EOS Commercial |
$6.23
|
| Rate for Payer: HFN Commercial |
$6.44
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5.25
|
| Rate for Payer: Multiplan Commercial |
$5.60
|
| Rate for Payer: NAPHCARE Commercial |
$4.20
|
| Rate for Payer: Preferred Network Access Commercial |
$6.44
|
| Rate for Payer: Quartz Beloit One Network |
$3.43
|
| Rate for Payer: Quartz Commercial |
$4.55
|
| Rate for Payer: Quartz Medicare Advantage |
$4.20
|
| Rate for Payer: The Alliance Commercial |
$28.00
|
| Rate for Payer: WEA Trust Commercial |
$3.85
|
| Rate for Payer: WPS Commercial |
$5.18
|
|
|
Sodium hyaluronate 20 mg/mL Soln - Durolane
|
Professional
|
Both
|
$37.00
|
|
|
Service Code
|
HCPCS J7318
|
| Hospital Charge Code |
5799848
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$6.14 |
| Max. Negotiated Rate |
$35.15 |
| Rate for Payer: Aetna Commercial |
$35.15
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$31.82
|
| Rate for Payer: Cash Price |
$11.10
|
| Rate for Payer: Cash Price |
$11.10
|
| Rate for Payer: Cigna Commercial |
$35.15
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$6.14
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$6.55
|
| Rate for Payer: Health EOS Commercial |
$33.67
|
| Rate for Payer: HFN Commercial |
$35.15
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$24.32
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$24.32
|
| Rate for Payer: Multiplan Commercial |
$29.60
|
| Rate for Payer: Preferred Network Access Commercial |
$35.15
|
| Rate for Payer: Quartz Beloit One Network |
$16.28
|
| Rate for Payer: Quartz Commercial |
$21.09
|
| Rate for Payer: The Alliance Commercial |
$18.50
|
| Rate for Payer: United Healthcare Medicaid |
$6.14
|
| Rate for Payer: WEA Trust Commercial |
$20.35
|
| Rate for Payer: WPS Commercial |
$16.38
|
|
|
Sodium hyaluronate 20 mg/mL Soln - Durolane
|
Facility
|
OP
|
$37.00
|
|
|
Service Code
|
HCPCS J7318
|
| Hospital Charge Code |
5799848
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$6.14 |
| Max. Negotiated Rate |
$34.04 |
| Rate for Payer: Aetna Commercial |
$33.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$31.82
|
| Rate for Payer: Aetna Managed Medicare |
$6.14
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$24.05
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$18.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$17.76
|
| Rate for Payer: Anthem Medicare Advantage |
$6.14
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$19.61
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$6.14
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$6.14
|
| Rate for Payer: Cash Price |
$11.10
|
| Rate for Payer: Cash Price |
$11.10
|
| Rate for Payer: Cigna Commercial |
$34.04
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$6.14
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$8.67
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$6.14
|
| Rate for Payer: Health EOS Commercial |
$32.93
|
| Rate for Payer: HFN Commercial |
$34.04
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$22.85
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$6.14
|
| Rate for Payer: Independent Care Health Plan Medicare |
$6.14
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$6.14
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$6.14
|
| Rate for Payer: Multiplan Commercial |
$29.60
|
| Rate for Payer: NAPHCARE Commercial |
$9.21
|
| Rate for Payer: Preferred Network Access Commercial |
$34.04
|
| Rate for Payer: Quartz Beloit One Network |
$18.13
|
| Rate for Payer: Quartz Commercial |
$24.05
|
| Rate for Payer: Quartz Medicare Advantage |
$6.14
|
| Rate for Payer: The Alliance Commercial |
$24.57
|
| Rate for Payer: United Healthcare Medicare Advantage |
$6.14
|
| Rate for Payer: WEA Trust Commercial |
$20.35
|
| Rate for Payer: Wellcare Medicare |
$6.14
|
| Rate for Payer: WPS Commercial |
$16.38
|
|
|
Sodium hyaluronate 20 mg/mL Soln - Durolane
|
Facility
|
IP
|
$37.00
|
|
|
Service Code
|
HCPCS J7318
|
| Hospital Charge Code |
5799848
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$18.13 |
| Max. Negotiated Rate |
$34.04 |
| Rate for Payer: Aetna Commercial |
$33.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$31.82
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$19.61
|
| Rate for Payer: Cash Price |
$11.10
|
| Rate for Payer: Cigna Commercial |
$34.04
|
| Rate for Payer: Health EOS Commercial |
$32.93
|
| Rate for Payer: HFN Commercial |
$34.04
|
| Rate for Payer: Multiplan Commercial |
$29.60
|
| Rate for Payer: NAPHCARE Commercial |
$22.20
|
| Rate for Payer: Preferred Network Access Commercial |
$34.04
|
| Rate for Payer: Quartz Beloit One Network |
$18.13
|
| Rate for Payer: Quartz Commercial |
$22.20
|
| Rate for Payer: WEA Trust Commercial |
$20.35
|
| Rate for Payer: WPS Commercial |
$27.41
|
|
|
Sodium Level
|
Facility
|
IP
|
$78.00
|
|
|
Service Code
|
CPT 84295
|
| Hospital Charge Code |
633611
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$38.22 |
| Max. Negotiated Rate |
$71.76 |
| Rate for Payer: Aetna Commercial |
$70.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$67.08
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$41.34
|
| Rate for Payer: Cash Price |
$23.40
|
| Rate for Payer: Cigna Commercial |
$71.76
|
| Rate for Payer: Health EOS Commercial |
$69.42
|
| Rate for Payer: HFN Commercial |
$71.76
|
| Rate for Payer: Multiplan Commercial |
$62.40
|
| Rate for Payer: NAPHCARE Commercial |
$46.80
|
| Rate for Payer: Preferred Network Access Commercial |
$71.76
|
| Rate for Payer: Quartz Beloit One Network |
$38.22
|
| Rate for Payer: Quartz Commercial |
$46.80
|
| Rate for Payer: WEA Trust Commercial |
$42.90
|
| Rate for Payer: WPS Commercial |
$57.77
|
|
|
Sodium Level
|
Facility
|
OP
|
$78.00
|
|
|
Service Code
|
CPT 84295
|
| Hospital Charge Code |
633611
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$4.81 |
| Max. Negotiated Rate |
$71.76 |
| Rate for Payer: Aetna Commercial |
$70.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$67.08
|
| Rate for Payer: Aetna Managed Medicare |
$4.81
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$18.04
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$8.42
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$7.98
|
| Rate for Payer: Anthem Medicaid |
$4.97
|
| Rate for Payer: Anthem Medicare Advantage |
$4.81
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$41.34
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$4.81
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$4.81
|
| Rate for Payer: Cash Price |
$23.40
|
| Rate for Payer: Cash Price |
$23.40
|
| Rate for Payer: Cigna Commercial |
$71.76
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$4.81
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$4.97
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$43.65
|
| Rate for Payer: Dean Health Medicaid |
$4.97
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$4.81
|
| Rate for Payer: Health EOS Commercial |
$69.42
|
| Rate for Payer: HFN Commercial |
$71.76
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$17.89
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$4.81
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$4.97
|
| Rate for Payer: Independent Care Health Plan Medicare |
$4.81
|
| Rate for Payer: Managed Health Services Medicaid |
$5.17
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$4.81
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$4.81
|
| Rate for Payer: Multiplan Commercial |
$62.40
|
| Rate for Payer: NAPHCARE Commercial |
$7.22
|
| Rate for Payer: Preferred Network Access Commercial |
$71.76
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$4.97
|
| Rate for Payer: Quartz Beloit One Network |
$38.22
|
| Rate for Payer: Quartz Commercial |
$50.70
|
| Rate for Payer: Quartz Medicare Advantage |
$4.81
|
| Rate for Payer: The Alliance Commercial |
$19.24
|
| Rate for Payer: United Healthcare Medicaid |
$4.97
|
| Rate for Payer: United Healthcare Medicare Advantage |
$4.81
|
| Rate for Payer: United Healthcare PPO |
$58.50
|
| Rate for Payer: WEA Trust Commercial |
$42.90
|
| Rate for Payer: Wellcare Medicare |
$4.81
|
| Rate for Payer: WMAP Medicaid |
$4.97
|
| Rate for Payer: WPS Commercial |
$57.77
|
|
|
Sodium Level
|
Professional
|
Both
|
$78.00
|
|
|
Service Code
|
CPT 84295
|
| Hospital Charge Code |
633611
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$16.98 |
| Max. Negotiated Rate |
$74.10 |
| Rate for Payer: Aetna Commercial |
$74.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$67.08
|
| Rate for Payer: Cash Price |
$23.40
|
| Rate for Payer: Cash Price |
$23.40
|
| Rate for Payer: Cigna Commercial |
$74.10
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$39.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$46.80
|
| Rate for Payer: Health EOS Commercial |
$70.98
|
| Rate for Payer: HFN Commercial |
$74.10
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$16.98
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$16.98
|
| Rate for Payer: Multiplan Commercial |
$62.40
|
| Rate for Payer: Preferred Network Access Commercial |
$74.10
|
| Rate for Payer: Quartz Beloit One Network |
$34.32
|
| Rate for Payer: Quartz Commercial |
$44.46
|
| Rate for Payer: The Alliance Commercial |
$39.00
|
| Rate for Payer: WEA Trust Commercial |
$42.90
|
| Rate for Payer: WPS Commercial |
$57.77
|
|
