|
Sulfa Mag 500 mg Charge
|
Facility
|
OP
|
$7.00
|
|
|
Service Code
|
HCPCS J3475
|
| Hospital Charge Code |
2958855
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.85 |
| 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: Cash Price |
$2.10
|
| Rate for Payer: Cigna Commercial |
$6.44
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$0.85
|
| 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 |
$1.61
|
|
|
Sulfa Mag 500 mg Charge
|
Facility
|
IP
|
$7.00
|
|
|
Service Code
|
HCPCS J3475
|
| Hospital Charge Code |
2958855
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3.43 |
| 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
|
|
|
Sulfa Mag 500 mg Charge
|
Professional
|
Both
|
$7.00
|
|
|
Service Code
|
HCPCS J3475
|
| Hospital Charge Code |
2958855
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.64 |
| Max. Negotiated Rate |
$6.65 |
| Rate for Payer: Aetna Commercial |
$6.65
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6.02
|
| Rate for Payer: Cash Price |
$2.10
|
| Rate for Payer: Cash Price |
$2.10
|
| Rate for Payer: Cigna Commercial |
$6.65
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$0.64
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$0.64
|
| Rate for Payer: Health EOS Commercial |
$6.37
|
| Rate for Payer: HFN Commercial |
$6.65
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$0.88
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$0.88
|
| Rate for Payer: Multiplan Commercial |
$5.60
|
| Rate for Payer: Preferred Network Access Commercial |
$6.65
|
| Rate for Payer: Quartz Beloit One Network |
$3.08
|
| Rate for Payer: Quartz Commercial |
$3.99
|
| Rate for Payer: The Alliance Commercial |
$3.50
|
| Rate for Payer: United Healthcare Medicaid |
$0.64
|
| Rate for Payer: WEA Trust Commercial |
$3.85
|
| Rate for Payer: WPS Commercial |
$1.61
|
|
|
Sulfate, Urine
|
Facility
|
IP
|
$29.00
|
|
|
Service Code
|
CPT 84392
|
| Hospital Charge Code |
5474691
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$14.21 |
| Max. Negotiated Rate |
$26.68 |
| Rate for Payer: Aetna Commercial |
$26.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$24.94
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$15.37
|
| Rate for Payer: Cash Price |
$8.70
|
| Rate for Payer: Cigna Commercial |
$26.68
|
| Rate for Payer: Health EOS Commercial |
$25.81
|
| Rate for Payer: HFN Commercial |
$26.68
|
| Rate for Payer: Multiplan Commercial |
$23.20
|
| Rate for Payer: NAPHCARE Commercial |
$17.40
|
| Rate for Payer: Preferred Network Access Commercial |
$26.68
|
| Rate for Payer: Quartz Beloit One Network |
$14.21
|
| Rate for Payer: Quartz Commercial |
$17.40
|
| Rate for Payer: WEA Trust Commercial |
$15.95
|
| Rate for Payer: WPS Commercial |
$21.48
|
|
|
Sulfate, Urine
|
Facility
|
OP
|
$29.00
|
|
|
Service Code
|
CPT 84392
|
| Hospital Charge Code |
5474691
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$5.49 |
| Max. Negotiated Rate |
$26.68 |
| Rate for Payer: Aetna Commercial |
$26.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$24.94
|
| Rate for Payer: Aetna Managed Medicare |
$5.49
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$20.59
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$9.61
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$9.11
|
| Rate for Payer: Anthem Medicaid |
$5.67
|
| Rate for Payer: Anthem Medicare Advantage |
$5.49
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$15.37
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$5.49
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$5.49
|
| Rate for Payer: Cash Price |
$8.70
|
| Rate for Payer: Cash Price |
$8.70
|
| Rate for Payer: Cigna Commercial |
$26.68
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$5.49
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$5.67
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$16.23
|
| Rate for Payer: Dean Health Medicaid |
$5.67
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$5.49
|
| Rate for Payer: Health EOS Commercial |
$25.81
|
| Rate for Payer: HFN Commercial |
$26.68
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$20.42
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$5.49
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$5.67
|
| Rate for Payer: Independent Care Health Plan Medicare |
$5.49
|
| Rate for Payer: Managed Health Services Medicaid |
$5.90
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$5.49
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$5.49
|
| Rate for Payer: Multiplan Commercial |
$23.20
|
| Rate for Payer: NAPHCARE Commercial |
$8.24
|
| Rate for Payer: Preferred Network Access Commercial |
$26.68
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$5.67
|
| Rate for Payer: Quartz Beloit One Network |
$14.21
|
| Rate for Payer: Quartz Commercial |
$18.85
|
| Rate for Payer: Quartz Medicare Advantage |
$5.49
|
| Rate for Payer: The Alliance Commercial |
$21.96
|
| Rate for Payer: United Healthcare Medicaid |
$5.67
|
| Rate for Payer: United Healthcare Medicare Advantage |
$5.49
|
| Rate for Payer: United Healthcare PPO |
$21.75
|
| Rate for Payer: WEA Trust Commercial |
$15.95
|
| Rate for Payer: Wellcare Medicare |
$5.49
|
| Rate for Payer: WMAP Medicaid |
$5.67
|
| Rate for Payer: WPS Commercial |
$21.48
|
|
|
Sulfate, Urine
|
Professional
|
Both
|
$29.00
|
|
|
Service Code
|
CPT 84392
|
| Hospital Charge Code |
5474691
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$12.76 |
| Max. Negotiated Rate |
$27.55 |
| Rate for Payer: Aetna Commercial |
$27.55
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$24.94
|
| Rate for Payer: Cash Price |
$8.70
|
| Rate for Payer: Cash Price |
$8.70
|
| Rate for Payer: Cigna Commercial |
$27.55
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$14.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$17.40
|
| Rate for Payer: Health EOS Commercial |
$26.39
|
| Rate for Payer: HFN Commercial |
$27.55
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$19.38
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$19.38
|
| Rate for Payer: Multiplan Commercial |
$23.20
|
| Rate for Payer: Preferred Network Access Commercial |
$27.55
|
| Rate for Payer: Quartz Beloit One Network |
$12.76
|
| Rate for Payer: Quartz Commercial |
$16.53
|
| Rate for Payer: The Alliance Commercial |
$14.50
|
| Rate for Payer: WEA Trust Commercial |
$15.95
|
| Rate for Payer: WPS Commercial |
$21.48
|
|
|
Sulfonamides Undifferentiated
|
Professional
|
Both
|
$108.00
|
|
|
Service Code
|
CPT 80299
|
| Hospital Charge Code |
4514646
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$47.52 |
| Max. Negotiated Rate |
$102.60 |
| Rate for Payer: Aetna Commercial |
$102.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$92.88
|
| Rate for Payer: Cash Price |
$32.40
|
| Rate for Payer: Cash Price |
$32.40
|
| Rate for Payer: Cigna Commercial |
$102.60
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$54.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$64.80
|
| Rate for Payer: Health EOS Commercial |
$98.28
|
| Rate for Payer: HFN Commercial |
$102.60
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$65.80
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$65.80
|
| Rate for Payer: Multiplan Commercial |
$86.40
|
| Rate for Payer: Preferred Network Access Commercial |
$102.60
|
| Rate for Payer: Quartz Beloit One Network |
$47.52
|
| Rate for Payer: Quartz Commercial |
$61.56
|
| Rate for Payer: The Alliance Commercial |
$54.00
|
| Rate for Payer: WEA Trust Commercial |
$59.40
|
| Rate for Payer: WPS Commercial |
$80.00
|
|
|
Sulfonamides Undifferentiated
|
Facility
|
IP
|
$108.00
|
|
|
Service Code
|
CPT 80299
|
| Hospital Charge Code |
4514646
|
|
Hospital Revenue Code
|
300
|
| 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
|
|
|
Sulfonamides Undifferentiated
|
Facility
|
OP
|
$108.00
|
|
|
Service Code
|
CPT 80299
|
| Hospital Charge Code |
4514646
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$18.64 |
| Max. Negotiated Rate |
$99.36 |
| Rate for Payer: Aetna Commercial |
$97.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$92.88
|
| Rate for Payer: Aetna Managed Medicare |
$18.64
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$69.90
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$32.62
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$30.94
|
| Rate for Payer: Anthem Medicaid |
$19.26
|
| Rate for Payer: Anthem Medicare Advantage |
$18.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$57.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$18.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$18.64
|
| Rate for Payer: Cash Price |
$32.40
|
| Rate for Payer: Cash Price |
$32.40
|
| Rate for Payer: Cigna Commercial |
$99.36
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$18.64
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$19.26
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$60.44
|
| Rate for Payer: Dean Health Medicaid |
$19.26
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$18.64
|
| Rate for Payer: Health EOS Commercial |
$96.12
|
| Rate for Payer: HFN Commercial |
$99.36
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$69.34
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$18.64
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$19.26
|
| Rate for Payer: Independent Care Health Plan Medicare |
$18.64
|
| Rate for Payer: Managed Health Services Medicaid |
$20.03
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$18.64
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$18.64
|
| Rate for Payer: Multiplan Commercial |
$86.40
|
| Rate for Payer: NAPHCARE Commercial |
$27.96
|
| Rate for Payer: Preferred Network Access Commercial |
$99.36
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$19.26
|
| Rate for Payer: Quartz Beloit One Network |
$52.92
|
| Rate for Payer: Quartz Commercial |
$70.20
|
| Rate for Payer: Quartz Medicare Advantage |
$18.64
|
| Rate for Payer: The Alliance Commercial |
$74.56
|
| Rate for Payer: United Healthcare Medicaid |
$19.26
|
| Rate for Payer: United Healthcare Medicare Advantage |
$18.64
|
| Rate for Payer: United Healthcare PPO |
$81.00
|
| Rate for Payer: WEA Trust Commercial |
$59.40
|
| Rate for Payer: Wellcare Medicare |
$18.64
|
| Rate for Payer: WMAP Medicaid |
$19.26
|
| Rate for Payer: WPS Commercial |
$80.00
|
|
|
Sumatriptan succinate / 6 mg J3030
|
Facility
|
OP
|
$186.00
|
|
|
Service Code
|
HCPCS J3030
|
| Hospital Charge Code |
3523501
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$52.08 |
| Max. Negotiated Rate |
$744.00 |
| Rate for Payer: Aetna Commercial |
$167.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$159.96
|
| Rate for Payer: Aetna Managed Medicare |
$52.08
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$120.90
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$93.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$89.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$98.58
|
| Rate for Payer: Cash Price |
$55.80
|
| Rate for Payer: Cigna Commercial |
$171.12
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$104.09
|
| Rate for Payer: Health EOS Commercial |
$165.54
|
| Rate for Payer: HFN Commercial |
$171.12
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$139.50
|
| Rate for Payer: Multiplan Commercial |
$148.80
|
| Rate for Payer: NAPHCARE Commercial |
$111.60
|
| Rate for Payer: Preferred Network Access Commercial |
$171.12
|
| Rate for Payer: Quartz Beloit One Network |
$91.14
|
| Rate for Payer: Quartz Commercial |
$120.90
|
| Rate for Payer: Quartz Medicare Advantage |
$111.60
|
| Rate for Payer: The Alliance Commercial |
$744.00
|
| Rate for Payer: WEA Trust Commercial |
$102.30
|
| Rate for Payer: WPS Commercial |
$137.77
|
|
|
Sumatriptan succinate / 6 mg J3030
|
Professional
|
Both
|
$186.00
|
|
|
Service Code
|
HCPCS J3030
|
| Hospital Charge Code |
3523501
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$51.89 |
| Max. Negotiated Rate |
$176.70 |
| Rate for Payer: Aetna Commercial |
$176.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$159.96
|
| Rate for Payer: Cash Price |
$55.80
|
| Rate for Payer: Cash Price |
$55.80
|
| Rate for Payer: Cigna Commercial |
$176.70
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$51.89
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$111.60
|
| Rate for Payer: Health EOS Commercial |
$169.26
|
| Rate for Payer: HFN Commercial |
$176.70
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$87.03
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$87.03
|
| Rate for Payer: Multiplan Commercial |
$148.80
|
| Rate for Payer: Preferred Network Access Commercial |
$176.70
|
| Rate for Payer: Quartz Beloit One Network |
$81.84
|
| Rate for Payer: Quartz Commercial |
$106.02
|
| Rate for Payer: The Alliance Commercial |
$93.00
|
| Rate for Payer: United Healthcare Medicaid |
$51.89
|
| Rate for Payer: WEA Trust Commercial |
$102.30
|
| Rate for Payer: WPS Commercial |
$137.77
|
|
|
Sumatriptan succinate / 6 mg J3030
|
Facility
|
IP
|
$186.00
|
|
|
Service Code
|
HCPCS J3030
|
| Hospital Charge Code |
3523501
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$91.14 |
| Max. Negotiated Rate |
$171.12 |
| Rate for Payer: Aetna Commercial |
$167.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$159.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$98.58
|
| Rate for Payer: Cash Price |
$55.80
|
| Rate for Payer: Cigna Commercial |
$171.12
|
| Rate for Payer: Health EOS Commercial |
$165.54
|
| Rate for Payer: HFN Commercial |
$171.12
|
| Rate for Payer: Multiplan Commercial |
$148.80
|
| Rate for Payer: NAPHCARE Commercial |
$111.60
|
| Rate for Payer: Preferred Network Access Commercial |
$171.12
|
| Rate for Payer: Quartz Beloit One Network |
$91.14
|
| Rate for Payer: Quartz Commercial |
$111.60
|
| Rate for Payer: WEA Trust Commercial |
$102.30
|
| Rate for Payer: WPS Commercial |
$137.77
|
|
|
SUMP CARDIAC 15FR 12010
|
Facility
|
OP
|
$266.00
|
|
| Hospital Charge Code |
2965379
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$74.48 |
| Max. Negotiated Rate |
$1,064.00 |
| Rate for Payer: Aetna Commercial |
$239.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$228.76
|
| Rate for Payer: Aetna Managed Medicare |
$74.48
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$172.90
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$133.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$127.68
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$140.98
|
| Rate for Payer: Cash Price |
$79.80
|
| Rate for Payer: Cigna Commercial |
$244.72
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$148.85
|
| Rate for Payer: Health EOS Commercial |
$236.74
|
| Rate for Payer: HFN Commercial |
$244.72
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$199.50
|
| Rate for Payer: Multiplan Commercial |
$212.80
|
| Rate for Payer: NAPHCARE Commercial |
$159.60
|
| Rate for Payer: Preferred Network Access Commercial |
$244.72
|
| Rate for Payer: Quartz Beloit One Network |
$130.34
|
| Rate for Payer: Quartz Commercial |
$172.90
|
| Rate for Payer: Quartz Medicare Advantage |
$159.60
|
| Rate for Payer: The Alliance Commercial |
$1,064.00
|
| Rate for Payer: WEA Trust Commercial |
$146.30
|
| Rate for Payer: WPS Commercial |
$197.03
|
|
|
SUMP CARDIAC 15FR 12010
|
Facility
|
IP
|
$266.00
|
|
| Hospital Charge Code |
2965379
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$130.34 |
| Max. Negotiated Rate |
$244.72 |
| Rate for Payer: Aetna Commercial |
$239.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$228.76
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$140.98
|
| Rate for Payer: Cash Price |
$79.80
|
| Rate for Payer: Cigna Commercial |
$244.72
|
| Rate for Payer: Health EOS Commercial |
$236.74
|
| Rate for Payer: HFN Commercial |
$244.72
|
| Rate for Payer: Multiplan Commercial |
$212.80
|
| Rate for Payer: NAPHCARE Commercial |
$159.60
|
| Rate for Payer: Preferred Network Access Commercial |
$244.72
|
| Rate for Payer: Quartz Beloit One Network |
$130.34
|
| Rate for Payer: Quartz Commercial |
$159.60
|
| Rate for Payer: WEA Trust Commercial |
$146.30
|
| Rate for Payer: WPS Commercial |
$197.03
|
|
|
SUMP CARDIAC 20FR 12112
|
Facility
|
OP
|
$277.00
|
|
| Hospital Charge Code |
2965380
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$77.56 |
| Max. Negotiated Rate |
$1,108.00 |
| Rate for Payer: Aetna Commercial |
$249.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$238.22
|
| Rate for Payer: Aetna Managed Medicare |
$77.56
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$180.05
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$138.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$132.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$146.81
|
| Rate for Payer: Cash Price |
$83.10
|
| Rate for Payer: Cigna Commercial |
$254.84
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$155.01
|
| Rate for Payer: Health EOS Commercial |
$246.53
|
| Rate for Payer: HFN Commercial |
$254.84
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$207.75
|
| Rate for Payer: Multiplan Commercial |
$221.60
|
| Rate for Payer: NAPHCARE Commercial |
$166.20
|
| Rate for Payer: Preferred Network Access Commercial |
$254.84
|
| Rate for Payer: Quartz Beloit One Network |
$135.73
|
| Rate for Payer: Quartz Commercial |
$180.05
|
| Rate for Payer: Quartz Medicare Advantage |
$166.20
|
| Rate for Payer: The Alliance Commercial |
$1,108.00
|
| Rate for Payer: WEA Trust Commercial |
$152.35
|
| Rate for Payer: WPS Commercial |
$205.17
|
|
|
SUMP CARDIAC 20FR 12112
|
Facility
|
IP
|
$277.00
|
|
| Hospital Charge Code |
2965380
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$135.73 |
| Max. Negotiated Rate |
$254.84 |
| Rate for Payer: Aetna Commercial |
$249.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$238.22
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$146.81
|
| Rate for Payer: Cash Price |
$83.10
|
| Rate for Payer: Cigna Commercial |
$254.84
|
| Rate for Payer: Health EOS Commercial |
$246.53
|
| Rate for Payer: HFN Commercial |
$254.84
|
| Rate for Payer: Multiplan Commercial |
$221.60
|
| Rate for Payer: NAPHCARE Commercial |
$166.20
|
| Rate for Payer: Preferred Network Access Commercial |
$254.84
|
| Rate for Payer: Quartz Beloit One Network |
$135.73
|
| Rate for Payer: Quartz Commercial |
$166.20
|
| Rate for Payer: WEA Trust Commercial |
$152.35
|
| Rate for Payer: WPS Commercial |
$205.17
|
|
|
Supera Stent
|
Facility
|
IP
|
$8,090.00
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
5184611
|
|
Hospital Revenue Code
|
481
|
| Min. Negotiated Rate |
$3,964.10 |
| Max. Negotiated Rate |
$7,442.80 |
| Rate for Payer: Aetna Commercial |
$7,281.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,957.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,287.70
|
| Rate for Payer: Cash Price |
$2,427.00
|
| Rate for Payer: Cigna Commercial |
$7,442.80
|
| Rate for Payer: Health EOS Commercial |
$7,200.10
|
| Rate for Payer: HFN Commercial |
$7,442.80
|
| Rate for Payer: Multiplan Commercial |
$6,472.00
|
| Rate for Payer: NAPHCARE Commercial |
$4,854.00
|
| Rate for Payer: Preferred Network Access Commercial |
$7,442.80
|
| Rate for Payer: Quartz Beloit One Network |
$3,964.10
|
| Rate for Payer: Quartz Commercial |
$4,854.00
|
| Rate for Payer: WEA Trust Commercial |
$4,449.50
|
| Rate for Payer: WPS Commercial |
$5,992.26
|
|
|
Supera Stent
|
Facility
|
OP
|
$8,090.00
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
5184611
|
|
Hospital Revenue Code
|
481
|
| Min. Negotiated Rate |
$2,265.20 |
| Max. Negotiated Rate |
$32,360.00 |
| Rate for Payer: Aetna Commercial |
$7,281.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,957.40
|
| Rate for Payer: Aetna Managed Medicare |
$2,265.20
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5,258.50
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,045.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,883.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,287.70
|
| Rate for Payer: Cash Price |
$2,427.00
|
| Rate for Payer: Cigna Commercial |
$7,442.80
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,527.16
|
| Rate for Payer: Health EOS Commercial |
$7,200.10
|
| Rate for Payer: HFN Commercial |
$7,442.80
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$6,067.50
|
| Rate for Payer: Multiplan Commercial |
$6,472.00
|
| Rate for Payer: NAPHCARE Commercial |
$4,854.00
|
| Rate for Payer: Preferred Network Access Commercial |
$7,442.80
|
| Rate for Payer: Quartz Beloit One Network |
$3,964.10
|
| Rate for Payer: Quartz Commercial |
$5,258.50
|
| Rate for Payer: Quartz Medicare Advantage |
$4,854.00
|
| Rate for Payer: The Alliance Commercial |
$32,360.00
|
| Rate for Payer: WEA Trust Commercial |
$4,449.50
|
| Rate for Payer: WPS Commercial |
$5,992.26
|
|
|
SUPERIOR LABRUM ANTERIOR POSTERIOR REPAIR (SLAP)
|
Facility
|
OP
|
$4,657.00
|
|
| Hospital Charge Code |
2950496
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,303.96 |
| Max. Negotiated Rate |
$18,628.00 |
| Rate for Payer: Aetna Commercial |
$4,191.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,005.02
|
| Rate for Payer: Aetna Managed Medicare |
$1,303.96
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,027.05
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,328.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,235.36
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,468.21
|
| Rate for Payer: Cash Price |
$1,397.10
|
| Rate for Payer: Cigna Commercial |
$4,284.44
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,606.06
|
| Rate for Payer: Health EOS Commercial |
$4,144.73
|
| Rate for Payer: HFN Commercial |
$4,284.44
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,492.75
|
| Rate for Payer: Multiplan Commercial |
$3,725.60
|
| Rate for Payer: NAPHCARE Commercial |
$2,794.20
|
| Rate for Payer: Preferred Network Access Commercial |
$4,284.44
|
| Rate for Payer: Quartz Beloit One Network |
$2,281.93
|
| Rate for Payer: Quartz Commercial |
$3,027.05
|
| Rate for Payer: Quartz Medicare Advantage |
$2,794.20
|
| Rate for Payer: The Alliance Commercial |
$18,628.00
|
| Rate for Payer: WEA Trust Commercial |
$2,561.35
|
| Rate for Payer: WPS Commercial |
$3,449.44
|
|
|
SUPERIOR LABRUM ANTERIOR POSTERIOR REPAIR (SLAP)
|
Facility
|
IP
|
$4,657.00
|
|
| Hospital Charge Code |
2950496
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$2,281.93 |
| Max. Negotiated Rate |
$4,284.44 |
| Rate for Payer: Aetna Commercial |
$4,191.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,005.02
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,468.21
|
| Rate for Payer: Cash Price |
$1,397.10
|
| Rate for Payer: Cigna Commercial |
$4,284.44
|
| Rate for Payer: Health EOS Commercial |
$4,144.73
|
| Rate for Payer: HFN Commercial |
$4,284.44
|
| Rate for Payer: Multiplan Commercial |
$3,725.60
|
| Rate for Payer: NAPHCARE Commercial |
$2,794.20
|
| Rate for Payer: Preferred Network Access Commercial |
$4,284.44
|
| Rate for Payer: Quartz Beloit One Network |
$2,281.93
|
| Rate for Payer: Quartz Commercial |
$2,794.20
|
| Rate for Payer: WEA Trust Commercial |
$2,561.35
|
| Rate for Payer: WPS Commercial |
$3,449.44
|
|
|
Suplena 8oz Can
|
Facility
|
OP
|
$6.00
|
|
|
Service Code
|
HCPCS B4154
|
| Hospital Charge Code |
3031454
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.68 |
| Max. Negotiated Rate |
$24.00 |
| Rate for Payer: Aetna Commercial |
$5.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5.16
|
| Rate for Payer: Aetna Managed Medicare |
$1.68
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3.90
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3.18
|
| Rate for Payer: Cash Price |
$1.80
|
| Rate for Payer: Cigna Commercial |
$5.52
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3.36
|
| Rate for Payer: Health EOS Commercial |
$5.34
|
| Rate for Payer: HFN Commercial |
$5.52
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4.50
|
| Rate for Payer: Multiplan Commercial |
$4.80
|
| Rate for Payer: NAPHCARE Commercial |
$3.60
|
| Rate for Payer: Preferred Network Access Commercial |
$5.52
|
| Rate for Payer: Quartz Beloit One Network |
$2.94
|
| Rate for Payer: Quartz Commercial |
$3.90
|
| Rate for Payer: Quartz Medicare Advantage |
$3.60
|
| Rate for Payer: The Alliance Commercial |
$24.00
|
| Rate for Payer: WEA Trust Commercial |
$3.30
|
| Rate for Payer: WPS Commercial |
$4.44
|
|
|
Suplena 8oz Can
|
Facility
|
IP
|
$6.00
|
|
|
Service Code
|
HCPCS B4154
|
| Hospital Charge Code |
3031454
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.94 |
| Max. Negotiated Rate |
$5.52 |
| Rate for Payer: Aetna Commercial |
$5.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5.16
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3.18
|
| Rate for Payer: Cash Price |
$1.80
|
| Rate for Payer: Cigna Commercial |
$5.52
|
| Rate for Payer: Health EOS Commercial |
$5.34
|
| Rate for Payer: HFN Commercial |
$5.52
|
| Rate for Payer: Multiplan Commercial |
$4.80
|
| Rate for Payer: NAPHCARE Commercial |
$3.60
|
| Rate for Payer: Preferred Network Access Commercial |
$5.52
|
| Rate for Payer: Quartz Beloit One Network |
$2.94
|
| Rate for Payer: Quartz Commercial |
$3.60
|
| Rate for Payer: WEA Trust Commercial |
$3.30
|
| Rate for Payer: WPS Commercial |
$4.44
|
|
|
SUPPORT ANKLE SWD WM 55116203
|
Facility
|
OP
|
$519.00
|
|
| Hospital Charge Code |
2971352
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$145.32 |
| Max. Negotiated Rate |
$2,076.00 |
| Rate for Payer: Aetna Commercial |
$467.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$446.34
|
| Rate for Payer: Aetna Managed Medicare |
$145.32
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$337.35
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$259.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$249.12
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$275.07
|
| Rate for Payer: Cash Price |
$155.70
|
| Rate for Payer: Cigna Commercial |
$477.48
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$290.43
|
| Rate for Payer: Health EOS Commercial |
$461.91
|
| Rate for Payer: HFN Commercial |
$477.48
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$389.25
|
| Rate for Payer: Multiplan Commercial |
$415.20
|
| Rate for Payer: NAPHCARE Commercial |
$311.40
|
| Rate for Payer: Preferred Network Access Commercial |
$477.48
|
| Rate for Payer: Quartz Beloit One Network |
$254.31
|
| Rate for Payer: Quartz Commercial |
$337.35
|
| Rate for Payer: Quartz Medicare Advantage |
$311.40
|
| Rate for Payer: The Alliance Commercial |
$2,076.00
|
| Rate for Payer: WEA Trust Commercial |
$285.45
|
| Rate for Payer: WPS Commercial |
$384.42
|
|
|
SUPPORT ANKLE SWD WM 55116203
|
Facility
|
IP
|
$519.00
|
|
| Hospital Charge Code |
2971352
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$254.31 |
| Max. Negotiated Rate |
$477.48 |
| Rate for Payer: Aetna Commercial |
$467.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$446.34
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$275.07
|
| Rate for Payer: Cash Price |
$155.70
|
| Rate for Payer: Cigna Commercial |
$477.48
|
| Rate for Payer: Health EOS Commercial |
$461.91
|
| Rate for Payer: HFN Commercial |
$477.48
|
| Rate for Payer: Multiplan Commercial |
$415.20
|
| Rate for Payer: NAPHCARE Commercial |
$311.40
|
| Rate for Payer: Preferred Network Access Commercial |
$477.48
|
| Rate for Payer: Quartz Beloit One Network |
$254.31
|
| Rate for Payer: Quartz Commercial |
$311.40
|
| Rate for Payer: WEA Trust Commercial |
$285.45
|
| Rate for Payer: WPS Commercial |
$384.42
|
|
|
SUPPORT ANKLE SWD WS 55116202
|
Facility
|
IP
|
$519.00
|
|
| Hospital Charge Code |
2971351
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$254.31 |
| Max. Negotiated Rate |
$477.48 |
| Rate for Payer: Aetna Commercial |
$467.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$446.34
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$275.07
|
| Rate for Payer: Cash Price |
$155.70
|
| Rate for Payer: Cigna Commercial |
$477.48
|
| Rate for Payer: Health EOS Commercial |
$461.91
|
| Rate for Payer: HFN Commercial |
$477.48
|
| Rate for Payer: Multiplan Commercial |
$415.20
|
| Rate for Payer: NAPHCARE Commercial |
$311.40
|
| Rate for Payer: Preferred Network Access Commercial |
$477.48
|
| Rate for Payer: Quartz Beloit One Network |
$254.31
|
| Rate for Payer: Quartz Commercial |
$311.40
|
| Rate for Payer: WEA Trust Commercial |
$285.45
|
| Rate for Payer: WPS Commercial |
$384.42
|
|
