|
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
|
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
|
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
|
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
|
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
|
|
|
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
|
|
|
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
|
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
|
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
|
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
|
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 |
$5.62
|
| Rate for Payer: WEA Trust Commercial |
$57.20
|
| Rate for Payer: WPS Commercial |
$3.39
|
|
|
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
|
Professional
|
Both
|
$100.00
|
|
|
Service Code
|
HCPCS J7040
|
| Hospital Charge Code |
4027269
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.34 |
| Max. Negotiated Rate |
$98.80 |
| Rate for Payer: Aetna Commercial |
$98.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$89.44
|
| Rate for Payer: Aetna Managed Medicare |
$1.40
|
| Rate for Payer: Anthem Medicare Advantage |
$1.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$1.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$1.40
|
| Rate for Payer: Cash Price |
$30.00
|
| Rate for Payer: Cash Price |
$30.00
|
| Rate for Payer: Cigna Commercial |
$98.80
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$1.34
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1.36
|
| Rate for Payer: Health EOS Commercial |
$94.64
|
| Rate for Payer: HFN Commercial |
$98.80
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2.12
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$2.12
|
| Rate for Payer: Independent Care Health Plan Medicare |
$1.40
|
| Rate for Payer: Multiplan Commercial |
$83.20
|
| Rate for Payer: NAPHCARE Commercial |
$2.11
|
| Rate for Payer: Preferred Network Access Commercial |
$98.80
|
| Rate for Payer: Quartz Beloit One Network |
$45.76
|
| Rate for Payer: Quartz Commercial |
$59.28
|
| Rate for Payer: Quartz Medicare Advantage |
$1.40
|
| Rate for Payer: The Alliance Commercial |
$3.86
|
| Rate for Payer: United Healthcare Medicaid |
$1.34
|
| Rate for Payer: United Healthcare Medicare Advantage |
$1.40
|
| Rate for Payer: WEA Trust Commercial |
$57.20
|
| Rate for Payer: WPS Commercial |
$3.39
|
|
|
SODIUM CHLORIDE 0.9% PF 10ML (MED)
|
Facility
|
OP
|
$7.00
|
|
| Hospital Charge Code |
5923704
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.04 |
| Max. Negotiated Rate |
$6.70 |
| Rate for Payer: Aetna Commercial |
$6.55
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6.26
|
| Rate for Payer: Aetna Managed Medicare |
$2.04
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4.73
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3.64
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3.49
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3.86
|
| Rate for Payer: Cash Price |
$2.10
|
| Rate for Payer: Cigna Commercial |
$6.70
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4.07
|
| Rate for Payer: Health EOS Commercial |
$6.48
|
| Rate for Payer: HFN Commercial |
$6.70
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5.46
|
| Rate for Payer: Multiplan Commercial |
$5.82
|
| Rate for Payer: NAPHCARE Commercial |
$4.37
|
| Rate for Payer: Preferred Network Access Commercial |
$6.70
|
| Rate for Payer: Quartz Beloit One Network |
$3.57
|
| Rate for Payer: Quartz Commercial |
$4.73
|
| Rate for Payer: Quartz Medicare Advantage |
$4.37
|
| Rate for Payer: The Alliance Commercial |
$3.64
|
| Rate for Payer: WEA Trust Commercial |
$4.00
|
| Rate for Payer: WPS Commercial |
$5.39
|
|
|
SODIUM CHLORIDE 0.9% PF 10ML (MED)
|
Facility
|
IP
|
$7.00
|
|
| Hospital Charge Code |
5923704
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.57 |
| Max. Negotiated Rate |
$6.70 |
| Rate for Payer: Aetna Commercial |
$6.55
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6.26
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3.86
|
| Rate for Payer: Cash Price |
$2.10
|
| Rate for Payer: Cigna Commercial |
$6.70
|
| Rate for Payer: Health EOS Commercial |
$6.48
|
| Rate for Payer: HFN Commercial |
$6.70
|
| Rate for Payer: Multiplan Commercial |
$5.82
|
| Rate for Payer: Preferred Network Access Commercial |
$6.70
|
| Rate for Payer: Quartz Beloit One Network |
$3.57
|
| Rate for Payer: Quartz Commercial |
$4.37
|
| Rate for Payer: WEA Trust Commercial |
$4.00
|
| Rate for Payer: WPS Commercial |
$5.39
|
|
|
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 |
$6.49 |
| Max. Negotiated Rate |
$36.56 |
| Rate for Payer: Aetna Commercial |
$36.56
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$33.09
|
| Rate for Payer: Aetna Managed Medicare |
$6.49
|
| Rate for Payer: Anthem Medicare Advantage |
$6.49
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$6.49
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$6.49
|
| Rate for Payer: Cash Price |
$11.10
|
| Rate for Payer: Cash Price |
$11.10
|
| Rate for Payer: Cigna Commercial |
$36.56
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$6.78
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$6.81
|
| Rate for Payer: Health EOS Commercial |
$35.02
|
| Rate for Payer: HFN Commercial |
$36.56
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$25.29
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$25.29
|
| Rate for Payer: Independent Care Health Plan Medicare |
$6.49
|
| Rate for Payer: Multiplan Commercial |
$30.78
|
| Rate for Payer: NAPHCARE Commercial |
$9.73
|
| Rate for Payer: Preferred Network Access Commercial |
$36.56
|
| Rate for Payer: Quartz Beloit One Network |
$16.93
|
| Rate for Payer: Quartz Commercial |
$21.93
|
| Rate for Payer: Quartz Medicare Advantage |
$6.49
|
| Rate for Payer: The Alliance Commercial |
$17.85
|
| Rate for Payer: United Healthcare Medicaid |
$6.78
|
| Rate for Payer: United Healthcare Medicare Advantage |
$6.49
|
| Rate for Payer: WEA Trust Commercial |
$21.16
|
| Rate for Payer: WPS Commercial |
$17.03
|
|
|
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 |
$6.49 |
| Max. Negotiated Rate |
$35.40 |
| Rate for Payer: Aetna Commercial |
$34.63
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$33.09
|
| Rate for Payer: Aetna Managed Medicare |
$6.49
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$25.01
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$19.24
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$18.47
|
| Rate for Payer: Anthem Medicare Advantage |
$6.49
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$20.39
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$6.49
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$6.49
|
| Rate for Payer: Cash Price |
$11.10
|
| Rate for Payer: Cash Price |
$11.10
|
| Rate for Payer: Cigna Commercial |
$35.40
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$6.49
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$9.01
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$6.49
|
| Rate for Payer: Health EOS Commercial |
$34.25
|
| Rate for Payer: HFN Commercial |
$35.40
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$24.14
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$6.49
|
| Rate for Payer: Independent Care Health Plan Medicare |
$6.49
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$6.49
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$6.49
|
| Rate for Payer: Multiplan Commercial |
$30.78
|
| Rate for Payer: NAPHCARE Commercial |
$9.73
|
| Rate for Payer: Preferred Network Access Commercial |
$35.40
|
| Rate for Payer: Quartz Beloit One Network |
$18.86
|
| Rate for Payer: Quartz Commercial |
$25.01
|
| Rate for Payer: Quartz Medicare Advantage |
$6.49
|
| Rate for Payer: The Alliance Commercial |
$25.96
|
| Rate for Payer: United Healthcare Medicare Advantage |
$6.49
|
| Rate for Payer: WEA Trust Commercial |
$21.16
|
| Rate for Payer: Wellcare Medicare |
$6.49
|
| Rate for Payer: WPS Commercial |
$17.03
|
|
|
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 |
$18.86 |
| Max. Negotiated Rate |
$35.40 |
| Rate for Payer: Aetna Commercial |
$34.63
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$33.09
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$20.39
|
| Rate for Payer: Cash Price |
$11.10
|
| Rate for Payer: Cigna Commercial |
$35.40
|
| Rate for Payer: Health EOS Commercial |
$34.25
|
| Rate for Payer: HFN Commercial |
$35.40
|
| Rate for Payer: Multiplan Commercial |
$30.78
|
| Rate for Payer: Preferred Network Access Commercial |
$35.40
|
| Rate for Payer: Quartz Beloit One Network |
$18.86
|
| Rate for Payer: Quartz Commercial |
$23.09
|
| Rate for Payer: WEA Trust Commercial |
$21.16
|
| Rate for Payer: WPS Commercial |
$28.50
|
|
|
Sodium Level
|
Professional
|
Both
|
$78.00
|
|
|
Service Code
|
CPT 84295
|
| Hospital Charge Code |
633611
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$5.00 |
| Max. Negotiated Rate |
$77.06 |
| Rate for Payer: Aetna Commercial |
$77.06
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$69.76
|
| Rate for Payer: Aetna Managed Medicare |
$5.00
|
| Rate for Payer: Anthem Medicare Advantage |
$5.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$5.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$5.00
|
| Rate for Payer: Cash Price |
$23.40
|
| Rate for Payer: Cash Price |
$23.40
|
| Rate for Payer: Cigna Commercial |
$77.06
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$40.56
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$5.00
|
| Rate for Payer: Health EOS Commercial |
$73.82
|
| Rate for Payer: HFN Commercial |
$77.06
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$17.66
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$17.66
|
| Rate for Payer: Independent Care Health Plan Medicare |
$5.00
|
| Rate for Payer: Multiplan Commercial |
$64.90
|
| Rate for Payer: NAPHCARE Commercial |
$7.50
|
| Rate for Payer: Preferred Network Access Commercial |
$77.06
|
| Rate for Payer: Quartz Beloit One Network |
$35.69
|
| Rate for Payer: Quartz Commercial |
$46.24
|
| Rate for Payer: Quartz Medicare Advantage |
$5.00
|
| Rate for Payer: The Alliance Commercial |
$19.76
|
| Rate for Payer: United Healthcare Medicare Advantage |
$5.00
|
| Rate for Payer: WEA Trust Commercial |
$44.62
|
| Rate for Payer: WPS Commercial |
$22.01
|
|
|
Sodium Level
|
Facility
|
OP
|
$78.00
|
|
|
Service Code
|
CPT 84295
|
| Hospital Charge Code |
633611
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$5.00 |
| Max. Negotiated Rate |
$74.63 |
| Rate for Payer: Aetna Commercial |
$73.01
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$69.76
|
| Rate for Payer: Aetna Managed Medicare |
$5.00
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$18.76
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$8.75
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$8.30
|
| Rate for Payer: Anthem Medicare Advantage |
$5.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$42.99
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$5.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$5.00
|
| Rate for Payer: Cash Price |
$23.40
|
| Rate for Payer: Cash Price |
$23.40
|
| Rate for Payer: Cigna Commercial |
$74.63
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$5.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$45.40
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$5.00
|
| Rate for Payer: Health EOS Commercial |
$72.20
|
| Rate for Payer: HFN Commercial |
$74.63
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$18.61
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$5.00
|
| Rate for Payer: Independent Care Health Plan Medicare |
$5.00
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$5.00
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$5.00
|
| Rate for Payer: Multiplan Commercial |
$64.90
|
| Rate for Payer: NAPHCARE Commercial |
$7.50
|
| Rate for Payer: Preferred Network Access Commercial |
$74.63
|
| Rate for Payer: Quartz Beloit One Network |
$39.75
|
| Rate for Payer: Quartz Commercial |
$52.73
|
| Rate for Payer: Quartz Medicare Advantage |
$5.00
|
| Rate for Payer: The Alliance Commercial |
$20.01
|
| Rate for Payer: United Healthcare Medicare Advantage |
$5.00
|
| Rate for Payer: United Healthcare PPO |
$60.84
|
| Rate for Payer: WEA Trust Commercial |
$44.62
|
| Rate for Payer: Wellcare Medicare |
$5.00
|
| Rate for Payer: WPS Commercial |
$60.08
|
|
|
Sodium Level
|
Facility
|
IP
|
$78.00
|
|
|
Service Code
|
CPT 84295
|
| Hospital Charge Code |
633611
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$39.75 |
| Max. Negotiated Rate |
$74.63 |
| Rate for Payer: Aetna Commercial |
$73.01
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$69.76
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$42.99
|
| Rate for Payer: Cash Price |
$23.40
|
| Rate for Payer: Cigna Commercial |
$74.63
|
| Rate for Payer: Health EOS Commercial |
$72.20
|
| Rate for Payer: HFN Commercial |
$74.63
|
| Rate for Payer: Multiplan Commercial |
$64.90
|
| Rate for Payer: Preferred Network Access Commercial |
$74.63
|
| Rate for Payer: Quartz Beloit One Network |
$39.75
|
| Rate for Payer: Quartz Commercial |
$48.67
|
| Rate for Payer: WEA Trust Commercial |
$44.62
|
| Rate for Payer: WPS Commercial |
$60.08
|
|
|
Sodium Level 24 Hour Urine
|
Facility
|
OP
|
$66.00
|
|
|
Service Code
|
CPT 84300
|
| Hospital Charge Code |
633613
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$5.26 |
| Max. Negotiated Rate |
$63.15 |
| Rate for Payer: Aetna Commercial |
$61.78
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$59.03
|
| Rate for Payer: Aetna Managed Medicare |
$5.26
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$19.73
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$9.21
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$8.74
|
| Rate for Payer: Anthem Medicare Advantage |
$5.26
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$36.38
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$5.26
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$5.26
|
| Rate for Payer: Cash Price |
$19.80
|
| Rate for Payer: Cash Price |
$19.80
|
| Rate for Payer: Cigna Commercial |
$63.15
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$5.26
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$38.41
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$5.26
|
| Rate for Payer: Health EOS Commercial |
$61.09
|
| Rate for Payer: HFN Commercial |
$63.15
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$19.58
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$5.26
|
| Rate for Payer: Independent Care Health Plan Medicare |
$5.26
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$5.26
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$5.26
|
| Rate for Payer: Multiplan Commercial |
$54.91
|
| Rate for Payer: NAPHCARE Commercial |
$7.89
|
| Rate for Payer: Preferred Network Access Commercial |
$63.15
|
| Rate for Payer: Quartz Beloit One Network |
$33.63
|
| Rate for Payer: Quartz Commercial |
$44.62
|
| Rate for Payer: Quartz Medicare Advantage |
$5.26
|
| Rate for Payer: The Alliance Commercial |
$21.05
|
| Rate for Payer: United Healthcare Medicare Advantage |
$5.26
|
| Rate for Payer: United Healthcare PPO |
$51.48
|
| Rate for Payer: WEA Trust Commercial |
$37.75
|
| Rate for Payer: Wellcare Medicare |
$5.26
|
| Rate for Payer: WPS Commercial |
$50.84
|
|
|
Sodium Level 24 Hour Urine
|
Professional
|
Both
|
$66.00
|
|
|
Service Code
|
CPT 84300
|
| Hospital Charge Code |
633613
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$5.26 |
| Max. Negotiated Rate |
$65.21 |
| Rate for Payer: Aetna Commercial |
$65.21
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$59.03
|
| Rate for Payer: Aetna Managed Medicare |
$5.26
|
| Rate for Payer: Anthem Medicare Advantage |
$5.26
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$5.26
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$5.26
|
| Rate for Payer: Cash Price |
$19.80
|
| Rate for Payer: Cash Price |
$19.80
|
| Rate for Payer: Cigna Commercial |
$65.21
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$34.32
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$5.26
|
| Rate for Payer: Health EOS Commercial |
$62.46
|
| Rate for Payer: HFN Commercial |
$65.21
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$18.57
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$18.57
|
| Rate for Payer: Independent Care Health Plan Medicare |
$5.26
|
| Rate for Payer: Multiplan Commercial |
$54.91
|
| Rate for Payer: NAPHCARE Commercial |
$7.89
|
| Rate for Payer: Preferred Network Access Commercial |
$65.21
|
| Rate for Payer: Quartz Beloit One Network |
$30.20
|
| Rate for Payer: Quartz Commercial |
$39.12
|
| Rate for Payer: Quartz Medicare Advantage |
$5.26
|
| Rate for Payer: The Alliance Commercial |
$20.79
|
| Rate for Payer: United Healthcare Medicare Advantage |
$5.26
|
| Rate for Payer: WEA Trust Commercial |
$37.75
|
| Rate for Payer: WPS Commercial |
$23.15
|
|
|
Sodium Level 24 Hour Urine
|
Facility
|
IP
|
$66.00
|
|
|
Service Code
|
CPT 84300
|
| Hospital Charge Code |
633613
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$33.63 |
| Max. Negotiated Rate |
$63.15 |
| Rate for Payer: Aetna Commercial |
$61.78
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$59.03
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$36.38
|
| Rate for Payer: Cash Price |
$19.80
|
| Rate for Payer: Cigna Commercial |
$63.15
|
| Rate for Payer: Health EOS Commercial |
$61.09
|
| Rate for Payer: HFN Commercial |
$63.15
|
| Rate for Payer: Multiplan Commercial |
$54.91
|
| Rate for Payer: Preferred Network Access Commercial |
$63.15
|
| Rate for Payer: Quartz Beloit One Network |
$33.63
|
| Rate for Payer: Quartz Commercial |
$41.18
|
| Rate for Payer: WEA Trust Commercial |
$37.75
|
| Rate for Payer: WPS Commercial |
$50.84
|
|
