|
SUCTION YANKAUER TIP ONLY K80
|
Facility
|
OP
|
$25.00
|
|
| Hospital Charge Code |
2963805
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$7.28 |
| Max. Negotiated Rate |
$23.92 |
| Rate for Payer: Aetna Commercial |
$23.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$22.36
|
| Rate for Payer: Aetna Managed Medicare |
$7.28
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$16.90
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$13.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$12.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$13.78
|
| Rate for Payer: Cash Price |
$7.50
|
| Rate for Payer: Cigna Commercial |
$23.92
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$14.55
|
| Rate for Payer: Health EOS Commercial |
$23.14
|
| Rate for Payer: HFN Commercial |
$23.92
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$19.50
|
| Rate for Payer: Multiplan Commercial |
$20.80
|
| Rate for Payer: NAPHCARE Commercial |
$15.60
|
| Rate for Payer: Preferred Network Access Commercial |
$23.92
|
| Rate for Payer: Quartz Beloit One Network |
$12.74
|
| Rate for Payer: Quartz Commercial |
$16.90
|
| Rate for Payer: Quartz Medicare Advantage |
$15.60
|
| Rate for Payer: The Alliance Commercial |
$13.00
|
| Rate for Payer: WEA Trust Commercial |
$14.30
|
| Rate for Payer: WPS Commercial |
$19.26
|
|
|
SUCTION YANKAUER TIP ONLY K80
|
Facility
|
IP
|
$25.00
|
|
| Hospital Charge Code |
2963805
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$12.74 |
| Max. Negotiated Rate |
$23.92 |
| Rate for Payer: Aetna Commercial |
$23.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$22.36
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$13.78
|
| Rate for Payer: Cash Price |
$7.50
|
| Rate for Payer: Cigna Commercial |
$23.92
|
| Rate for Payer: Health EOS Commercial |
$23.14
|
| Rate for Payer: HFN Commercial |
$23.92
|
| Rate for Payer: Multiplan Commercial |
$20.80
|
| Rate for Payer: Preferred Network Access Commercial |
$23.92
|
| Rate for Payer: Quartz Beloit One Network |
$12.74
|
| Rate for Payer: Quartz Commercial |
$15.60
|
| Rate for Payer: WEA Trust Commercial |
$14.30
|
| Rate for Payer: WPS Commercial |
$19.26
|
|
|
Sugammadex 200mg/2ml vial (MED)
|
Facility
|
IP
|
$588.00
|
|
| Hospital Charge Code |
5597559
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$299.64 |
| Max. Negotiated Rate |
$562.60 |
| Rate for Payer: Aetna Commercial |
$550.37
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$525.91
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$324.11
|
| Rate for Payer: Cash Price |
$176.40
|
| Rate for Payer: Cigna Commercial |
$562.60
|
| Rate for Payer: Health EOS Commercial |
$544.25
|
| Rate for Payer: HFN Commercial |
$562.60
|
| Rate for Payer: Multiplan Commercial |
$489.22
|
| Rate for Payer: Preferred Network Access Commercial |
$562.60
|
| Rate for Payer: Quartz Beloit One Network |
$299.64
|
| Rate for Payer: Quartz Commercial |
$366.91
|
| Rate for Payer: WEA Trust Commercial |
$336.34
|
| Rate for Payer: WPS Commercial |
$452.94
|
|
|
Sugammadex 200mg/2ml vial (MED)
|
Facility
|
OP
|
$588.00
|
|
| Hospital Charge Code |
5597559
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$171.23 |
| Max. Negotiated Rate |
$562.60 |
| Rate for Payer: Aetna Commercial |
$550.37
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$525.91
|
| Rate for Payer: Aetna Managed Medicare |
$171.23
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$397.49
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$305.76
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$293.53
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$324.11
|
| Rate for Payer: Cash Price |
$176.40
|
| Rate for Payer: Cigna Commercial |
$562.60
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$342.22
|
| Rate for Payer: Health EOS Commercial |
$544.25
|
| Rate for Payer: HFN Commercial |
$562.60
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$458.64
|
| Rate for Payer: Multiplan Commercial |
$489.22
|
| Rate for Payer: NAPHCARE Commercial |
$366.91
|
| Rate for Payer: Preferred Network Access Commercial |
$562.60
|
| Rate for Payer: Quartz Beloit One Network |
$299.64
|
| Rate for Payer: Quartz Commercial |
$397.49
|
| Rate for Payer: Quartz Medicare Advantage |
$366.91
|
| Rate for Payer: The Alliance Commercial |
$305.76
|
| Rate for Payer: WEA Trust Commercial |
$336.34
|
| Rate for Payer: WPS Commercial |
$452.94
|
|
|
Sulfa Mag 500 mg Charge
|
Facility
|
OP
|
$7.00
|
|
|
Service Code
|
HCPCS J3475
|
| Hospital Charge Code |
2958855
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.88 |
| 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: Cash Price |
$2.10
|
| Rate for Payer: Cigna Commercial |
$6.70
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$0.88
|
| 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 |
$1.71
|
| Rate for Payer: WEA Trust Commercial |
$4.00
|
| Rate for Payer: WPS Commercial |
$1.67
|
|
|
Sulfa Mag 500 mg Charge
|
Professional
|
Both
|
$7.00
|
|
|
Service Code
|
HCPCS J3475
|
| Hospital Charge Code |
2958855
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.43 |
| Max. Negotiated Rate |
$6.92 |
| Rate for Payer: Aetna Commercial |
$6.92
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6.26
|
| Rate for Payer: Aetna Managed Medicare |
$0.43
|
| Rate for Payer: Anthem Medicare Advantage |
$0.43
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$0.43
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$0.43
|
| Rate for Payer: Cash Price |
$2.10
|
| Rate for Payer: Cash Price |
$2.10
|
| Rate for Payer: Cigna Commercial |
$6.92
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$0.43
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$0.67
|
| Rate for Payer: Health EOS Commercial |
$6.62
|
| Rate for Payer: HFN Commercial |
$6.92
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$0.92
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$0.92
|
| Rate for Payer: Independent Care Health Plan Medicare |
$0.43
|
| Rate for Payer: Multiplan Commercial |
$5.82
|
| Rate for Payer: NAPHCARE Commercial |
$0.64
|
| Rate for Payer: Preferred Network Access Commercial |
$6.92
|
| Rate for Payer: Quartz Beloit One Network |
$3.20
|
| Rate for Payer: Quartz Commercial |
$4.15
|
| Rate for Payer: Quartz Medicare Advantage |
$0.43
|
| Rate for Payer: The Alliance Commercial |
$1.17
|
| Rate for Payer: United Healthcare Medicaid |
$0.43
|
| Rate for Payer: United Healthcare Medicare Advantage |
$0.43
|
| Rate for Payer: WEA Trust Commercial |
$4.00
|
| Rate for Payer: WPS Commercial |
$1.67
|
|
|
Sulfa Mag 500 mg Charge
|
Facility
|
IP
|
$7.00
|
|
|
Service Code
|
HCPCS J3475
|
| Hospital Charge Code |
2958855
|
|
Hospital Revenue Code
|
636
|
| 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
|
|
|
Sulfate, Urine
|
Facility
|
OP
|
$29.00
|
|
|
Service Code
|
CPT 84392
|
| Hospital Charge Code |
5474691
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$5.71 |
| Max. Negotiated Rate |
$27.75 |
| Rate for Payer: Aetna Commercial |
$27.14
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$25.94
|
| Rate for Payer: Aetna Managed Medicare |
$5.71
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$21.41
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$9.99
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$9.48
|
| Rate for Payer: Anthem Medicare Advantage |
$5.71
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$15.98
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$5.71
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$5.71
|
| Rate for Payer: Cash Price |
$8.70
|
| Rate for Payer: Cash Price |
$8.70
|
| Rate for Payer: Cigna Commercial |
$27.75
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$5.71
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$16.88
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$5.71
|
| Rate for Payer: Health EOS Commercial |
$26.84
|
| Rate for Payer: HFN Commercial |
$27.75
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$21.24
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$5.71
|
| Rate for Payer: Independent Care Health Plan Medicare |
$5.71
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$5.71
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$5.71
|
| Rate for Payer: Multiplan Commercial |
$24.13
|
| Rate for Payer: NAPHCARE Commercial |
$8.56
|
| Rate for Payer: Preferred Network Access Commercial |
$27.75
|
| Rate for Payer: Quartz Beloit One Network |
$14.78
|
| Rate for Payer: Quartz Commercial |
$19.60
|
| Rate for Payer: Quartz Medicare Advantage |
$5.71
|
| Rate for Payer: The Alliance Commercial |
$22.84
|
| Rate for Payer: United Healthcare Medicare Advantage |
$5.71
|
| Rate for Payer: United Healthcare PPO |
$22.62
|
| Rate for Payer: WEA Trust Commercial |
$16.59
|
| Rate for Payer: Wellcare Medicare |
$5.71
|
| Rate for Payer: WPS Commercial |
$22.34
|
|
|
Sulfate, Urine
|
Professional
|
Both
|
$29.00
|
|
|
Service Code
|
CPT 84392
|
| Hospital Charge Code |
5474691
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$5.71 |
| Max. Negotiated Rate |
$28.65 |
| Rate for Payer: Aetna Commercial |
$28.65
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$25.94
|
| Rate for Payer: Aetna Managed Medicare |
$5.71
|
| Rate for Payer: Anthem Medicare Advantage |
$5.71
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$5.71
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$5.71
|
| Rate for Payer: Cash Price |
$8.70
|
| Rate for Payer: Cash Price |
$8.70
|
| Rate for Payer: Cigna Commercial |
$28.65
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$15.08
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$5.71
|
| Rate for Payer: Health EOS Commercial |
$27.45
|
| Rate for Payer: HFN Commercial |
$28.65
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$20.16
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$20.16
|
| Rate for Payer: Independent Care Health Plan Medicare |
$5.71
|
| Rate for Payer: Multiplan Commercial |
$24.13
|
| Rate for Payer: NAPHCARE Commercial |
$8.56
|
| Rate for Payer: Preferred Network Access Commercial |
$28.65
|
| Rate for Payer: Quartz Beloit One Network |
$13.27
|
| Rate for Payer: Quartz Commercial |
$17.19
|
| Rate for Payer: Quartz Medicare Advantage |
$5.71
|
| Rate for Payer: The Alliance Commercial |
$22.55
|
| Rate for Payer: United Healthcare Medicare Advantage |
$5.71
|
| Rate for Payer: WEA Trust Commercial |
$16.59
|
| Rate for Payer: WPS Commercial |
$25.12
|
|
|
Sulfate, Urine
|
Facility
|
IP
|
$29.00
|
|
|
Service Code
|
CPT 84392
|
| Hospital Charge Code |
5474691
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$14.78 |
| Max. Negotiated Rate |
$27.75 |
| Rate for Payer: Aetna Commercial |
$27.14
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$25.94
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$15.98
|
| Rate for Payer: Cash Price |
$8.70
|
| Rate for Payer: Cigna Commercial |
$27.75
|
| Rate for Payer: Health EOS Commercial |
$26.84
|
| Rate for Payer: HFN Commercial |
$27.75
|
| Rate for Payer: Multiplan Commercial |
$24.13
|
| Rate for Payer: Preferred Network Access Commercial |
$27.75
|
| Rate for Payer: Quartz Beloit One Network |
$14.78
|
| Rate for Payer: Quartz Commercial |
$18.10
|
| Rate for Payer: WEA Trust Commercial |
$16.59
|
| Rate for Payer: WPS Commercial |
$22.34
|
|
|
Sulfonamides Undifferentiated
|
Facility
|
OP
|
$108.00
|
|
|
Service Code
|
CPT 80299
|
| Hospital Charge Code |
4514646
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$19.39 |
| 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 |
$19.39
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$72.70
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$33.92
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$32.18
|
| Rate for Payer: Anthem Medicare Advantage |
$19.39
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$59.53
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$19.39
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$19.39
|
| Rate for Payer: Cash Price |
$32.40
|
| Rate for Payer: Cash Price |
$32.40
|
| Rate for Payer: Cigna Commercial |
$103.33
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$19.39
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$62.86
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$19.39
|
| Rate for Payer: Health EOS Commercial |
$99.96
|
| Rate for Payer: HFN Commercial |
$103.33
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$72.11
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$19.39
|
| Rate for Payer: Independent Care Health Plan Medicare |
$19.39
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$19.39
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$19.39
|
| Rate for Payer: Multiplan Commercial |
$89.86
|
| Rate for Payer: NAPHCARE Commercial |
$29.08
|
| 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 |
$19.39
|
| Rate for Payer: The Alliance Commercial |
$77.54
|
| Rate for Payer: United Healthcare Medicare Advantage |
$19.39
|
| Rate for Payer: United Healthcare PPO |
$84.24
|
| Rate for Payer: WEA Trust Commercial |
$61.78
|
| Rate for Payer: Wellcare Medicare |
$19.39
|
| Rate for Payer: WPS Commercial |
$83.19
|
|
|
Sulfonamides Undifferentiated
|
Professional
|
Both
|
$108.00
|
|
|
Service Code
|
CPT 80299
|
| Hospital Charge Code |
4514646
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$19.39 |
| Max. Negotiated Rate |
$106.70 |
| Rate for Payer: Aetna Commercial |
$106.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$96.60
|
| Rate for Payer: Aetna Managed Medicare |
$19.39
|
| Rate for Payer: Anthem Medicare Advantage |
$19.39
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$19.39
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$19.39
|
| Rate for Payer: Cash Price |
$32.40
|
| Rate for Payer: Cash Price |
$32.40
|
| Rate for Payer: Cigna Commercial |
$106.70
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$56.16
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$19.39
|
| Rate for Payer: Health EOS Commercial |
$102.21
|
| Rate for Payer: HFN Commercial |
$106.70
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$68.43
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$68.43
|
| Rate for Payer: Independent Care Health Plan Medicare |
$19.39
|
| Rate for Payer: Multiplan Commercial |
$89.86
|
| Rate for Payer: NAPHCARE Commercial |
$29.08
|
| Rate for Payer: Preferred Network Access Commercial |
$106.70
|
| Rate for Payer: Quartz Beloit One Network |
$49.42
|
| Rate for Payer: Quartz Commercial |
$64.02
|
| Rate for Payer: Quartz Medicare Advantage |
$19.39
|
| Rate for Payer: The Alliance Commercial |
$76.57
|
| Rate for Payer: United Healthcare Medicare Advantage |
$19.39
|
| Rate for Payer: WEA Trust Commercial |
$61.78
|
| Rate for Payer: WPS Commercial |
$85.30
|
|
|
Sulfonamides Undifferentiated
|
Facility
|
IP
|
$108.00
|
|
|
Service Code
|
CPT 80299
|
| Hospital Charge Code |
4514646
|
|
Hospital Revenue Code
|
300
|
| 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
|
|
|
Sumatriptan succinate / 6 mg J3030
|
Professional
|
Both
|
$186.00
|
|
|
Service Code
|
HCPCS J3030
|
| Hospital Charge Code |
3523501
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$53.97 |
| Max. Negotiated Rate |
$183.77 |
| Rate for Payer: Aetna Commercial |
$183.77
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$166.36
|
| Rate for Payer: Cash Price |
$55.80
|
| Rate for Payer: Cash Price |
$55.80
|
| Rate for Payer: Cigna Commercial |
$183.77
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$53.97
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$116.06
|
| Rate for Payer: Health EOS Commercial |
$176.03
|
| Rate for Payer: HFN Commercial |
$183.77
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$90.51
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$90.51
|
| Rate for Payer: Multiplan Commercial |
$154.75
|
| Rate for Payer: Preferred Network Access Commercial |
$183.77
|
| Rate for Payer: Quartz Beloit One Network |
$85.11
|
| Rate for Payer: Quartz Commercial |
$110.26
|
| Rate for Payer: The Alliance Commercial |
$96.72
|
| Rate for Payer: United Healthcare Medicaid |
$53.97
|
| Rate for Payer: WEA Trust Commercial |
$106.39
|
| Rate for Payer: WPS Commercial |
$143.28
|
|
|
Sumatriptan succinate / 6 mg J3030
|
Facility
|
OP
|
$186.00
|
|
|
Service Code
|
HCPCS J3030
|
| Hospital Charge Code |
3523501
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$54.16 |
| Max. Negotiated Rate |
$177.96 |
| Rate for Payer: Aetna Commercial |
$174.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$166.36
|
| Rate for Payer: Aetna Managed Medicare |
$54.16
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$125.74
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$96.72
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$92.85
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$102.52
|
| Rate for Payer: Cash Price |
$55.80
|
| Rate for Payer: Cigna Commercial |
$177.96
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$108.25
|
| Rate for Payer: Health EOS Commercial |
$172.16
|
| Rate for Payer: HFN Commercial |
$177.96
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$145.08
|
| Rate for Payer: Multiplan Commercial |
$154.75
|
| Rate for Payer: NAPHCARE Commercial |
$116.06
|
| Rate for Payer: Preferred Network Access Commercial |
$177.96
|
| Rate for Payer: Quartz Beloit One Network |
$94.79
|
| Rate for Payer: Quartz Commercial |
$125.74
|
| Rate for Payer: Quartz Medicare Advantage |
$116.06
|
| Rate for Payer: The Alliance Commercial |
$96.72
|
| Rate for Payer: WEA Trust Commercial |
$106.39
|
| Rate for Payer: WPS Commercial |
$143.28
|
|
|
Sumatriptan succinate / 6 mg J3030
|
Facility
|
IP
|
$186.00
|
|
|
Service Code
|
HCPCS J3030
|
| Hospital Charge Code |
3523501
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$94.79 |
| Max. Negotiated Rate |
$177.96 |
| Rate for Payer: Aetna Commercial |
$174.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$166.36
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$102.52
|
| Rate for Payer: Cash Price |
$55.80
|
| Rate for Payer: Cigna Commercial |
$177.96
|
| Rate for Payer: Health EOS Commercial |
$172.16
|
| Rate for Payer: HFN Commercial |
$177.96
|
| Rate for Payer: Multiplan Commercial |
$154.75
|
| Rate for Payer: Preferred Network Access Commercial |
$177.96
|
| Rate for Payer: Quartz Beloit One Network |
$94.79
|
| Rate for Payer: Quartz Commercial |
$116.06
|
| Rate for Payer: WEA Trust Commercial |
$106.39
|
| Rate for Payer: WPS Commercial |
$143.28
|
|
|
SUMP CARDIAC 15FR 12010
|
Facility
|
OP
|
$266.00
|
|
| Hospital Charge Code |
2965379
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$77.46 |
| Max. Negotiated Rate |
$254.51 |
| Rate for Payer: Aetna Commercial |
$248.98
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$237.91
|
| Rate for Payer: Aetna Managed Medicare |
$77.46
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$179.82
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$138.32
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$132.79
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$146.62
|
| Rate for Payer: Cash Price |
$79.80
|
| Rate for Payer: Cigna Commercial |
$254.51
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$154.81
|
| Rate for Payer: Health EOS Commercial |
$246.21
|
| Rate for Payer: HFN Commercial |
$254.51
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$207.48
|
| Rate for Payer: Multiplan Commercial |
$221.31
|
| Rate for Payer: NAPHCARE Commercial |
$165.98
|
| Rate for Payer: Preferred Network Access Commercial |
$254.51
|
| Rate for Payer: Quartz Beloit One Network |
$135.55
|
| Rate for Payer: Quartz Commercial |
$179.82
|
| Rate for Payer: Quartz Medicare Advantage |
$165.98
|
| Rate for Payer: The Alliance Commercial |
$138.32
|
| Rate for Payer: WEA Trust Commercial |
$152.15
|
| Rate for Payer: WPS Commercial |
$204.90
|
|
|
SUMP CARDIAC 15FR 12010
|
Facility
|
IP
|
$266.00
|
|
| Hospital Charge Code |
2965379
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$135.55 |
| Max. Negotiated Rate |
$254.51 |
| Rate for Payer: Aetna Commercial |
$248.98
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$237.91
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$146.62
|
| Rate for Payer: Cash Price |
$79.80
|
| Rate for Payer: Cigna Commercial |
$254.51
|
| Rate for Payer: Health EOS Commercial |
$246.21
|
| Rate for Payer: HFN Commercial |
$254.51
|
| Rate for Payer: Multiplan Commercial |
$221.31
|
| Rate for Payer: Preferred Network Access Commercial |
$254.51
|
| Rate for Payer: Quartz Beloit One Network |
$135.55
|
| Rate for Payer: Quartz Commercial |
$165.98
|
| Rate for Payer: WEA Trust Commercial |
$152.15
|
| Rate for Payer: WPS Commercial |
$204.90
|
|
|
SUMP CARDIAC 20FR 12112
|
Facility
|
OP
|
$277.00
|
|
| Hospital Charge Code |
2965380
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$80.66 |
| Max. Negotiated Rate |
$265.03 |
| Rate for Payer: Aetna Commercial |
$259.27
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$247.75
|
| Rate for Payer: Aetna Managed Medicare |
$80.66
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$187.25
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$144.04
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$138.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$152.68
|
| Rate for Payer: Cash Price |
$83.10
|
| Rate for Payer: Cigna Commercial |
$265.03
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$161.21
|
| Rate for Payer: Health EOS Commercial |
$256.39
|
| Rate for Payer: HFN Commercial |
$265.03
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$216.06
|
| Rate for Payer: Multiplan Commercial |
$230.46
|
| Rate for Payer: NAPHCARE Commercial |
$172.85
|
| Rate for Payer: Preferred Network Access Commercial |
$265.03
|
| Rate for Payer: Quartz Beloit One Network |
$141.16
|
| Rate for Payer: Quartz Commercial |
$187.25
|
| Rate for Payer: Quartz Medicare Advantage |
$172.85
|
| Rate for Payer: The Alliance Commercial |
$144.04
|
| Rate for Payer: WEA Trust Commercial |
$158.44
|
| Rate for Payer: WPS Commercial |
$213.37
|
|
|
SUMP CARDIAC 20FR 12112
|
Facility
|
IP
|
$277.00
|
|
| Hospital Charge Code |
2965380
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$141.16 |
| Max. Negotiated Rate |
$265.03 |
| Rate for Payer: Aetna Commercial |
$259.27
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$247.75
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$152.68
|
| Rate for Payer: Cash Price |
$83.10
|
| Rate for Payer: Cigna Commercial |
$265.03
|
| Rate for Payer: Health EOS Commercial |
$256.39
|
| Rate for Payer: HFN Commercial |
$265.03
|
| Rate for Payer: Multiplan Commercial |
$230.46
|
| Rate for Payer: Preferred Network Access Commercial |
$265.03
|
| Rate for Payer: Quartz Beloit One Network |
$141.16
|
| Rate for Payer: Quartz Commercial |
$172.85
|
| Rate for Payer: WEA Trust Commercial |
$158.44
|
| Rate for Payer: WPS Commercial |
$213.37
|
|
|
Supera Stent
|
Facility
|
OP
|
$8,090.00
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
5184611
|
|
Hospital Revenue Code
|
481
|
| Min. Negotiated Rate |
$2,355.81 |
| Max. Negotiated Rate |
$7,740.51 |
| Rate for Payer: Aetna Commercial |
$7,572.24
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,235.70
|
| Rate for Payer: Aetna Managed Medicare |
$2,355.81
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5,468.84
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,206.80
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,038.53
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,459.21
|
| Rate for Payer: Cash Price |
$2,427.00
|
| Rate for Payer: Cigna Commercial |
$7,740.51
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,708.38
|
| Rate for Payer: Health EOS Commercial |
$7,488.10
|
| Rate for Payer: HFN Commercial |
$7,740.51
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$6,310.20
|
| Rate for Payer: Multiplan Commercial |
$6,730.88
|
| Rate for Payer: NAPHCARE Commercial |
$5,048.16
|
| Rate for Payer: Preferred Network Access Commercial |
$7,740.51
|
| Rate for Payer: Quartz Beloit One Network |
$4,122.66
|
| Rate for Payer: Quartz Commercial |
$5,468.84
|
| Rate for Payer: Quartz Medicare Advantage |
$5,048.16
|
| Rate for Payer: The Alliance Commercial |
$4,206.80
|
| Rate for Payer: WEA Trust Commercial |
$4,627.48
|
| Rate for Payer: WPS Commercial |
$6,231.73
|
|
|
Supera Stent
|
Facility
|
IP
|
$8,090.00
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
5184611
|
|
Hospital Revenue Code
|
481
|
| Min. Negotiated Rate |
$4,122.66 |
| Max. Negotiated Rate |
$7,740.51 |
| Rate for Payer: Aetna Commercial |
$7,572.24
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,235.70
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,459.21
|
| Rate for Payer: Cash Price |
$2,427.00
|
| Rate for Payer: Cigna Commercial |
$7,740.51
|
| Rate for Payer: Health EOS Commercial |
$7,488.10
|
| Rate for Payer: HFN Commercial |
$7,740.51
|
| Rate for Payer: Multiplan Commercial |
$6,730.88
|
| Rate for Payer: Preferred Network Access Commercial |
$7,740.51
|
| Rate for Payer: Quartz Beloit One Network |
$4,122.66
|
| Rate for Payer: Quartz Commercial |
$5,048.16
|
| Rate for Payer: WEA Trust Commercial |
$4,627.48
|
| Rate for Payer: WPS Commercial |
$6,231.73
|
|
|
SUPERFICIAL INJURY TO SKIN AND SUBCUTANEOUS TISSUE
|
Facility
|
OP
|
$119.24
|
|
|
Service Code
|
EAPG 00777
|
| Min. Negotiated Rate |
$114.65 |
| Max. Negotiated Rate |
$119.24 |
| Rate for Payer: Anthem Medicaid |
$114.65
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO |
$114.65
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$114.65
|
| Rate for Payer: Dean Health Medicaid |
$114.65
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$114.65
|
| Rate for Payer: Managed Health Services Medicaid |
$119.24
|
| Rate for Payer: Molina Healthcare Medicaid |
$114.65
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$114.65
|
| Rate for Payer: United Healthcare Medicaid |
$114.65
|
|
|
SUPERFICIAL NEEDLE BIOPSY AND ASPIRATION
|
Facility
|
OP
|
$361.64
|
|
|
Service Code
|
EAPG 00002
|
| Min. Negotiated Rate |
$347.73 |
| Max. Negotiated Rate |
$361.64 |
| Rate for Payer: Anthem Medicaid |
$347.73
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO |
$347.73
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$347.73
|
| Rate for Payer: Dean Health Medicaid |
$347.73
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$347.73
|
| Rate for Payer: Managed Health Services Medicaid |
$361.64
|
| Rate for Payer: Molina Healthcare Medicaid |
$347.73
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$347.73
|
| Rate for Payer: United Healthcare Medicaid |
$347.73
|
|
|
SUPERIOR LABRUM ANTERIOR POSTERIOR REPAIR (SLAP)
|
Facility
|
OP
|
$4,657.00
|
|
| Hospital Charge Code |
2950496
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,356.12 |
| Max. Negotiated Rate |
$4,455.82 |
| Rate for Payer: Aetna Commercial |
$4,358.95
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,165.22
|
| Rate for Payer: Aetna Managed Medicare |
$1,356.12
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,148.13
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,421.64
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,324.77
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,566.94
|
| Rate for Payer: Cash Price |
$1,397.10
|
| Rate for Payer: Cigna Commercial |
$4,455.82
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,710.37
|
| Rate for Payer: Health EOS Commercial |
$4,310.52
|
| Rate for Payer: HFN Commercial |
$4,455.82
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,632.46
|
| Rate for Payer: Multiplan Commercial |
$3,874.62
|
| Rate for Payer: NAPHCARE Commercial |
$2,905.97
|
| Rate for Payer: Preferred Network Access Commercial |
$4,455.82
|
| Rate for Payer: Quartz Beloit One Network |
$2,373.21
|
| Rate for Payer: Quartz Commercial |
$3,148.13
|
| Rate for Payer: Quartz Medicare Advantage |
$2,905.97
|
| Rate for Payer: The Alliance Commercial |
$2,421.64
|
| Rate for Payer: WEA Trust Commercial |
$2,663.80
|
| Rate for Payer: WPS Commercial |
$3,587.29
|
|
